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Home My WebLink About0820 PUTNAM AVENUE - Health 820 PUTNAM AVENUE, COTUIT A= 039 074 I qA L O C AT IO�j SEWAGE PERMIT NO. VILLAGE � INST LLER'S NAME i ADDRESS �9 UZ B U I L D E R OR OWNER G� erg lAqkd7 DATE PERMIT ISSUED a aU DAT E COMPLIANCE ISSUED r 41� 0 ��► No....`.��..�. ....... Fins............................ THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ... ....................O F.............-..-..........-..-.-......-------------------........-.......-.......-....._. Apptira#ion for Dispas al. lVarkii Tonstrnr#inn ramit Application is hereby made for a Permit to Construct ()() or Repair ( ) an Individual Sewage Disposal stem at• . aa__•��-� . && ( u --......... ............ _.._...._... .. ..._.. ........... ......................... Locati Addre s o 0 Owner Address ....... L— ................................ ---•---.._.._._..._..._... ---..........--•----.......------•-----•. Installer Address Type of Building Size Lot_.-:��_ �._..Sq. feet Dwelling—No. of Bedrooms._.____.�.............................Expansion Attic ' ) Garbage Grinder (4eP Other—Type of Building No. of persons............................ Showers — Cafeteria Q' Other fixtures ------•--•••-•-•----• •---••-••••--••••••-••••-•-••--•••••--•-•----------•-•-•-•---------•-----•-•-•-••---•--•-•-••-•-•••-••--....--•...._..._--•••- d - � Design Tank—Liquid ®city.� gallon ss per Length en per day. Total daily ...Diameter________________ Depth---dons. Disposal Trench—No_..........._gip. Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No.....1P"AhIlZmeter-------------•._F Depth below inlet....._.............. Total leaching----- _i s . ft. Y g ( > ----- ............................ Date-•-•--.................................. Z Other bution box-(- Percolation r1Test Results Performed by tank q j ,.a Test Pit No. 1................minutes per inch Depth of Tes ----------_. Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit..............._.... Depth to ground water........................ a ...................... ....................................................----.......•--- . ._......----••-...........----....._. 0 Description of Soil---yu 1.®,�Ay �v �S c-L>..........-M-...Fit>.... ............A .... V .....---•----••..._••------•-•-•--•--_.... -•••-•-••-•.............••---••---•----...........•••-•--•••-•---•---•----•--•--•-----•-------•---•-•----•-••••-.......----....-•------......-•••--••--••-- W -•--•----------------------------------------------------•-•-•-•----•---------------•-•-•-••--•---••---•-•••-•••---------...-------•-----------=---••••••-•--•----•--...••-••-•---•--•----=--•----_----- UNature of Repairs or Alterations—Answer when applicable............................................................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TLII'iZ 5 of the State Saint ry Code—The u ersigned further agrees not to place the system in operation until a Certificate of Compliance has een issued by th oard q1het igne _ --i_. ..: i � � . D Date Application Approved By ..... ... - ...C%_..... -.L ......._..--•---••-•------ Date Application Disapproved for the following reasons----------------•----...--------•------------------------------•----------------...---••••-•-•---•----...._....._ ---•-••••-•-•-•_.._..•••....-•-•....--••---••-•--•-•-••----•-------_•--------•••••-------••------------------•-•-•-----•-••-----•-•-•••--•••---•-•---------------------••-----•------------........... Date PermitNo......................................................... Issued_._,.),__=.L.------7 :,r------•--•--------------- Date No.. ....••-•.......... Fic.............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...............................OF..................................................... Appliration for Disposal Works Tonstrurtion Vamit Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal System at, AM................. Locati V�rrys U)4.1 rvlov�� ...................... ...................... ................. ................ Ownet Address .............................................................. ................................. .................................... Installer Address Type of Building Size Lot...............J-0.6....Sq. feet Dwelling No. of Bedrooms............................................Expansion A it ic-,(4 Garbage Grinder of* Other—Type of Building •............................ No. of persons..........P.................. Showers Cafeteria','(- P4Other fixtures ...............I...................................................................................................5 - i 'T................................... � .3 0 ly,flow Design Flow.........I ...........................gallons per person,per day. Total d� I -------- ..................................gallons. P4 Septic Tank—i-iquid'cap4city.i.*"-.ga"Ilons Length________________ Width__ :t�Diameter..._......_._._. Depth_._- .... Deepage isposal Trench—No. Width.................... Total Length................._Total leaching area....................sq. ft. Pit No.....W"_$ TaThAer...;................. Depth below inlet..................... Total leachinz area ft. Dosing k Z Oilier Distribution box` )�4 UP Percolation Test Results Performed by........tt.... Date-A.0y... 1.4 ....... .......... Test Pitl;No. 1............n.,...mintites per inch Depth-tte -Dep*t-h--to ground water........................ (Z Test Pf No. 2.........,,_..._minutes per inch Depth of Test Pit;.................. Depth to gr6iind water________________________ 04 ................................................................................................... ................0:-------------------- 0 Description of ............ .............Wil ............0........................ ------------------------------------------------------------------------------------- ------*------*---------------------....................................................................... ......................................................................7......................................................................................................... Z .., l ,�------------------I U Nature of Repairs or Alterations—Answer when applicable........................ . ........................................................................ ........................................................................................................................................................................................................ . Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TLITIZ 5 of ffie:State San't ry Code--The u ersigned further agrees.not to place the system in I '_ G — I operation until a Certi&ate of C6 pliance has issued by h Xoard of heAt t.. . ..... Sig n n7d.1 .446AKAvA... . ..... ....... .............. --------------------- z� .Date Application Approved By....-e .2 ........ ............................ ... ........................................ --- 4o;j ;-I- Date Application Disapproved for the following reasons:................................................................................................................ ...................................................................................................................................... ...................... ................................ Date Permit No.----- ..................................................... IssuedL_2::_.4....Zf..:...................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD Or HEALTH .... 0 F ............................................... .. ....... . "(9rdifiratr of Tontlifiattrr, T I !l 0 1 TI That the Individual Sewage Disposal System constructed or Repaired T C ag ------------ by---- --- •.......... •....... ---77--------------------I............ ...................................................... ........ ---- ....... ...... .. ----- at..... ....... .. has been instal ed in accordance visions of T f he State Sanitary Code as describe in the 06 ........... 4 application for Disposal Works Construction Permit N -------- dated-_49._�; THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CON' STRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.......... ......................................... Inspeptor.. ......... ............................................... THE COMMONWEALTH OF MASSACHUSETTS,.� BOARD OF7 HEALTH F0 .. .. .. ............................ ............... FEE.:..._................. Permission s hereby grante&.:!.... ............ .................... ------------- -------- ------- to Constiu OoRep4a n du ..,age sal ..y t at Sc .,� -------4-ft ......4 Street 5 as shown on the application for Disposal Works Construction Perini tRp..... .. .... . Da- e,0� ___________________ L ... 0. ........ .............. ....... ---6, Board of Health— DATE..... k.............X..9............................................. FORM 1255 HOBBS & WARREN. INC., PUBLISHERS d Z ZLo 7- "y/o Z07— ID ci 4 O � a o to T t18 +ll �,Cp 56'D Dom/VE1 c/ i T ,— i I � V �T ze oN ASS✓H�� T�.4�r.�-j CERTIFIED PLOT PLAN EDWAR€J E. KELLEY LOCATION .C9-?v!.77, CUlj't4,t,Q,lU,l?, MASS. 0?637 SCALE . ��=30 . . . DATE p44..�./`178 - . - - - PLAN REFERENCE . Cov,,&T .� EDGE PD L Y y 3 J I CERTIFY THAT THE ! !NG fo✓n/Df►T70�J SHOWN ON THIS PLAN IS LOCATED ON THE GROUND Y's*F�v AS SHOWN HEREON AND THAT IT CONFORMS TO THE SETBACK REQUIREMENTS OF THE TOWN OF L�1,1,e /`1CGACH . . .4 15> !477—,1 44 . . . . . . WHEN CONSTRUCTED. /6 � c G4+N ems" DATE Dec. S /J`78. PETITIONER: S•ov77-1 V4kfio4,7711 /9.9ss- £'. SURV REGISTEREEDD LAND SURVEYOR TOP OF FOUNDATION CONCRETE COVER CONCRETE COVERS 0 4"CAST IRON 12"MAX. • 12"MAX. ' • PIPE (OR 4"ORANGEBURG(OR EQUIVA EQUIV.)- MIN. PIPE- MIN. LEACH � PITCH 1/4"PER. PITCH 1/4"PER.FT PIT PRECAST . ° J LEACHING NVERT a EL.. INVERT INVERT e . e•`e' PIT OR SEPTIC TANK �,S DIST. ,�6 w ';c EQUIV. EL.4z'. . . . . BOX EL.... 9.. ' : >x . . , o INVERT /ppp GAL. INVERT d �a Q. .�. `e; EL.4Z 3z.. "' INVERT . ww 0 •� 3/4��T0 IV , I EL. EL4/.00 e. w o p WASHED STONE 12, .. DIA PROR LE OF GROUND WATER TABLE SEWAGE DISPOSAL SYSTEM NO SCALE 1;SOIL LOG REE L I AA TE BY : DATE egW,A?, �'M. TIME. . . .. . . . . . . / G BOARD OF HEALTH TEST HOLE I TEST HOLE 2 ,77.10^ 45. t-, ENGINEER ELEV. . 4"./ . . ELEV. .. .. . . . . . . N V%°7 / 578 Wo�Loa, suBSO�� DESIGN DATA Z411 lB NUMBER OF BEDROOMS Pew- TOTAL ESTIMATED FLOW 330 GALLONS/DAY HE��ur� BOTTOM LEACHING AREA .78'S . . SO.FT. /PIT TO SIDE LEACHING AREA SQ.FT./ PIT faF . 56r�D GARBAGE DISPOSAL NONE- (50% AREA INCREASE) C 7L,7- TOTAL LEACHING AREA . . Z67oo . SQ.FT J/44 h" PERCOLATION RATE &?S .�,41 .7WO. MIN/INCH LEACHING AREA PER PERCOLATION RATE SQ.FT. .N.O.WATER ENCOUNTERED NUMBER OF LEACHING PITS T3vo FEAT of Spa vE on/ �DFaTE: ELLE�Y'CO. APPROVED . . . . . . . . . . . . BOARD OF HEALTH ' OF S70",- /?�-A-1 Al7T ENGINEERS-SURVEYORS 346 DATE . . . LONG POND DRIVE . . . . . . . . . . . . . . SOUTH YARMOU AGENT OR INSPECTOR .<^J .OZ OFM �9LOT .cs' E J,,{,h�•` F`i%. � THO �C/TNA 7E OTc�/ T/MASS ' N L"LrY cf;i + d K E y v 24 0 � - /� / ~FC��TfF� �- GIST6Q�' IONAL PETITIONER : • ct-�U P(ATNPM Xf, C oT w� a ' �QYeg c� r. . ADZ Ca Q-P-OCQ O . 14-10 I �(S � COM.vIONWEALTH OF MASSACHUSETTS , ' E.UCUTI'VE OFFICE OF ENVIRONMENTAL AFF DEPARTMENT OF ENVIRONMENTAL PRO sot t' ONE WINTER STREET. BOSTON. MA 02108 617-292-::00 199, ®..' cc W'ILLIAM F.WELD C X Govemoe ecsta ARGEO PAUL CELLUCCI D B.sTfmi- Lt.Govemor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Common PART A CERTIFICATION Property Address: ` Address of Owner- ` 6 Date of Inspection: (p/ /�i� (If different) jPG 60f 7 0/ Name of Inspector. �Chi � 1�s4� �0]'7J 1 T r Mif I am a DEP approved system inspgctor pursuant to Section 15.340 of Title 5 (310 CMR 1�.00 ) Q IS Company Name: ci 6l s� Mailing Address: 1, A, Telephone Number: <_Z2 rfz ae fong4!�p CERTIFICATION STATE?NENT . I certify.that I have oersonally inspected the sewage disposal system at this address and that the.intormation reported.below is true, accurzee and complete as of the :ime of insoecaion. The'inspecion was performed based on my training and experience in the prooer function arc maintenance of on-site sewage:disposal.systems. The system: _ 1passes" ... Conditionally. Passes weeds Further Evaluation By the Local Approving Authority _ 'rail Inspector's Signature: e Date The System Inspector sn submit-a copv of this inspection report to the approving Authority within thirty (30) days of completing Mis insoection. If the system is a shared system or has a design flow of 110,000 gpd or greater, the inroec or and the system owner shall submit the recort to the aooroeriate reetonal crfice of'he Department of Environmental Protection. The ortemal should be sent to the system ogre, and copies sent to the buyer. if applicaole, and the approving authority. INSPECTION SUMMARY: Check. A, a, C, w. D Aj SYSTEM PA55ES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 11303. Any failure criteria not evaluated are indicated below. - COMMENTS: _-5—C7 54 AjBIB!7/sue !2&De a BI SYSTEM CONDITIONALLY.PASSES: E One or mo" components as described in the "Conditional Pass" secion need to be replaced or repaired The system, upol completion of,the.replaceme air, as approved by the Board of Health,.wil Indicate ves, no, or not determined (Y, N, or'ND). D ba f determination in all instances. -!f"hot determined", explain why not. _ The septic tank is m Less the-owner or operator " ros�v,dea,:he system �nsoec or with a copy of a Certificate of Compii ached) indicating that the ank was installed witnt`z,« (erttvv 20) years prior 'o the gate of the nspection; c e septic tank, whether or not metal, is cracked. strucuraily unsound. shows suostant-tai r.rIuttra�uon or exfil;ration, or tan.- faiiure is imminent. The system will pass inspection 4 the existing septic tank ,s reoiaceo wtt, a co rrat Ong septic 'ank as aooroved by the Board of Health. �• :evaed. J4.'=5 971 Page 1 of 10 GE?on:ne:'!oral Wide Wet) ❑tr•rwww rnagner state ra-s.cec i v + SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner:� Date of Inspection . I " YNDITIONALLY PASSES (continued) YY C 7 Bl S .., - ` i ue t <7en obstructed Sewage backup;or breakout or high static waterlevel observed in the distribution box s dor due to a broken, settled or uneven distribution box. The system will pass i coon if(with approval of the Board of Describe observations: n pipe(s) are replaced obstruct removed distribution box i elled o aced — The system required pu la more than four times a due to broken or obstructed pipe(s). The system will pass inspection a trait approvai of the Board of Health): broken pipe are replaced obstruction is removed Cj. FU REVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions st which require further evaluation by the Board of Health in order to ae.e rmine if the syste vfaili" ng to protect the public health, sa and the environment. 1) SYSTEM WILL PASS UNL BOARD..OF HEALTH DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER WHICH WILL PROTECT THE L1C HEALTH AND SAFETY AND`THE ENVIRONM _ Cesspool or privy is within 50 t _ f a surface water _ Cesspool or privy is within 50 feet of a rdering vegetated w and or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (A UBLIC WATER S E PUBLIC HEALTH AND SAPLIER, IF FETY AN CTEHTEERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER TH OTE TH ENVIRONMENT: The system has a septic tank d soil absorption system 1SAS) and the SA within 100 feet to a surface water supply or tributary to a surface w r suooir. supply _ The system `(as a tic tank and soil absorption system and the SAS s within a Zone of a public watervWeil. _ The system ri septic tank and soil absorption system and the SAS is within 50 feet of a vate water supp . _ The syste as a septic tank_and soil absorption system and the SAS is :ess than 100 feet but 5 'eet or more from a priv water supply well, unless a well water analysis for co bat era and volatile organic corn r�ur+ds indicates the Weil is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrog is equal to 0 less than 5 pp m. Method used to determine distance (approximation not valid). 3) OTHER — i I Page 2 of 10 trsvised 04/:5/97) I t SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: Date of Inspection: DI SYSTEM FAILS: You must indicate en- er "Yes" or"No" as to each of the following: I have determined that the system violates one or more of the following failure criteria as defined in 310 GMR 303. The basis for thi determination is identified below. The Board of Health should be contacted to determine what wii a necessary to correct the failu ` Yes No Backup 'sewage into facility or system component due to an overloaded or ci ed SAS or cesspool. Discharge or p ding of effluent to the surface of the ground or surfac aters due to an overioaded or clogged SAS or cesspool. Static liquid level in the ' tribution box above oudet i rt due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less n 6" below ' ert or available volume is less than V2 day flow. t . Required pumping more than a time a last year NOT due to clogged or obstructed pipe(s). Number of times pumped _. Any portionrof the moil: orption.Sviiem, cesspooi"or ivy is below the high ;roundwater elevation- - Any portion of spool or privy is within 100 feet of a surfac ater supply or tributary to a surface water supply. Any po n of a cesspool or privy is within a Zone l of a public"Wei I. — . — portion of a cesspool or privy is within 50 feet_of a private water suppiv weii. A.nv portion of a cesspool or oriw is less than 100 feet but greater than SO feet from a pr to water supply well with no acceptable water.quality analvsis. If the weil has been analvzed to be acceptable. attach coot' of well water analysis for coiiform bacteria. yoiatile organic compounds, ammonia nitrogen and nitrate nitrogen. , LARG" STEM FAILS: You'm:st'indicat her -Yes" or`"Nq- as to each-of the toilo"Yir;=: The following : is aop y to large systems in.adaitior. to the criteria above: The system serves a facility wit design flow of 10.000 gpd or greater (Large Svst the system is a significant threat to public health anq safety and the envir ent because one or more o ;o owine conditions exist: Yes. No the s stem is within 400 feet of a surface drinkin water supply y the system is with' _00 feet of a tributary to a surface - king water supply _ the sv is located in a nitrogen sensitive area (Interim Well d Protection area- ;WPA) or a maoped Zone II of a p ' c water supply welh -The owner ooerator of any such system shall brine the system and facility into full compiiar,. wuh the grqund�.ater treatment program require. . nts or 314 ,".`tR 3.00 and 6.00. Please consult the Iocai regional office or the Depar me or urne nrormation. :ev:9ed 04/25. M ?�q� SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM. PART B CHECKLIST Property Address: Owner: Date of Inspection: Check if the following have been done: You must indicate either "Yes" or"No" as to each of the following: Yey No Pumping information was provided by the owner, occupant, or Board of Health. 2Z been None of the system codmtponeiha`pe�iad been largeooiumes oted for at ewater have not been ncroducedast two weeks and the system antother system grecently lor flow rates g as part of this inspection. _ As built plans have been obtained and examined. Note ;i they are not available with N/A. _ The facility or dwelling was inspected for signs of sewage back-up. _ The system does not receive non-sanitary or industrial waste flow. s�( _ The site was inspected.for signs of breakout. All system components, excluding the Soil Absorption System, have been located on the site. . ,.depth of,sludge; depth of scum: The septic tank mannoies were uncovered, opened, and the intenor�ot the septic tank--was jnspected for condition of .baffles or tees, material ofconstruction; dimensions, depth.of..liquid The size and location of the Soil Absorption System on the site has been determined based on: _ The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub-Surface Disposal System. _ Existing information. Ex. Plan at B.O.H. Determined in the field (if anv of the failure criteria reiated to Part C is at issue, approximation of distance is unacceptable! (13.3021,3)(b)] page 4 0. :0 (revised 04/:5/97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: Owner: „ s' Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow: &.4 gl1bedroom for S.A.S. Number of bedrooms. Number of current residents. Garbage grinder (yes or no):�Z() Laundry connected to system (yes or no): Seasonal use (yes or no):&) ':hater meter readings, if available (last two (3,1 year usage tgpd): Sump Pump (yes or no): A/0 Last date of occupancy: C MERCIAUINDUSTRIAL: Type o biishment: Design flow: " ai l ons/day Grease trap present: rye o) _ _ Industrial Waste Holding Tanis or _ Non-sanitari waste-dis to the �ute tem:,.,aes or_nol_ Water met )ngs, -if Last Last date or occupancy: " OTHER: ;Describe) Last date of occupant~ GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as part of insoec:cn: ;,yes or no:� (f yes, volume pumped: gaiions Reason for pumping: TYPE F 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) I/A Technology etc. Copy of up to date contract? Other APPROXIMATE AGE of all components, date installed (if known) and source of information: Sewage odors detected when arriving at the site: ;ves or no) /Y revised 04/:5/9') ?age 5 of`.:0 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued),:, Property Address: Owner: Date of Inspection: 10 N SYSTEM (SAS): SOIL ABSORPTION site approximated by non-intrusive methods) (locate on site plan, if possible; excavation not required, but may be If not determined to be present, explain: Type: leaching pits, number: leaching chambers, number:_ leaching galleries, nurnber: leaching trenches, number,length: leaching fields. number, dimensions: overflow cesspool, number: Alternative system: Name of Technology: Comments: mote condition of soli, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) .0 CESSPO S. ". (locate on si Ian) 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- inflo _s000l must be oumoed as part of inspection) Comments: l hydraulic failure, level of ponding, condition of vegetation, etc.) ote condition of soil, signs of PRIVY: _ (locate on site plan) Dimensions: Materials of construction: Cepth of solids: Comments: rioce con n of soil. signs of hvdrauiic faiiure. level of ponding, co itton of vegetation, etc. Page 2 of 10 �revijed 04/25/97, SUBSURFA CE SEWAGE.DISPOSAL SYSTEM INSPECTION FORM PART C f 'w SYSTEM INFORMATION (continued) ' P Property Address: Owner: Date of Inspection: BUILDING SEWER: (Locate on site plan) , Depth below gr material of construct( cast iron _ 40 PVC _other (explain) Distance from private water supply w r suction line Diameter t Comments: ;condition of join , venting, evidence of ea �. SEPTIC TANK: (locate on site plan) Depth below grade: Material of construcnon- oncrete _metal _Fibergiass.-_Polyethylene _other(explain) If lank is metal, list age- 'ls age confirmed.by Certificate of Compliance =,Yes/',:ol -- . Dimensions 4CINLsrJ Sludge depth: 3 t Distance from too of sludge to bottom of outlet tee or baffle:3 q Scum thickness: Distance from top of scum to top of outlet tee or battle: 3 Distance from bottom of scum to bottom of outlet tee or b :l�� How dimensions were determined: Comments: (recommendation for pumping, condition of inlet outlet ;ees or harries. depth of liquid level in relation to outlet invert, structural• inteenrv, evidence of ieaKaee, etc.; d t•, r g: . GREASE T P: (locate on site t Depth below grade: Material of construction: _concre metal'_Fiberglass _Poiyethyl _othenexplair,l Dimensions: Scum thickness. 4 Distance from top of scum to top or outlet tee orb Distance from bottom of scum to bottom of o t tee or baffle: Date ot�last pumping: Comments: (recommendation for pum g, condifton 'or'iniet and outlet-tees or,barties. depth or liquic vel in relation ;o outlet invert str�c urai integrity,, evidence of Kage, etc.: Peg* 6 o: 10 (revised 04/75.'37. '"..?`G`tW`'s.t.,.;f w<`•+.x yt+r lyF iw. !a•1 „" SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: TIGHT OR HOLDING TANK: (lank must be pumped prior to, or at time, of inspection) ' (locate on site plan) Depth below de: Material of construct concrete _metal _Fiberglass _Polyethylene other(explain) Dimensions: Capaciry: gallons Design flow: _ gallonsidav Alarm level: Alarm in working order s; _ Date of previous pumping: Comments: (condition of inlet tee, conditio alarm and float switches, etc.) DISTRIBUTION BOX:_ (locate on site plan) Depth of liquid level above outlet invert: Q Comments: mote if level and distribution is equal, evidence or solids carryover, evidence of'leakage'into or out of box, etc) PUMP CH MBER:._, (locate on site p a , Pumps in working order: (Yes or No) Alarms in working order (Yes or -No) Comments: (note condition of pump chamber, condition mps and appurtenances, etc.) Page 7 of 10 (revised 04/25i97) SUBSURFACE SEWAGE DISPOSAL,SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: 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) p. �5 Page 9 of :0 Izeviasd J�;=S!971 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: Depth to Groundwater Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from 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 Use USGS Data Describe in your own words how you established the High Groundwater Elevation. !Must be compieted) 3 3 11-7 13" idq G2oj/AA0 Page 10 of (revised 04/:5/97)