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Home My WebLink About0039 EEL RIVER ROAD - Health 39 Eel River Road Osterville P A = 116 105 No... 4 --y__S-- Figac a -THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ......................... ......OF....................................... Appliration for Uifipaoal Works Cnomilrurtion Pumit Application is hereby made for a Permit to Construct ( ) or Repair V11510'an Individual Sewage Disposal System at: -as...I-\--- =---_ �•1................................................................................................ at- n-Address- �df Lot No w Owner` A ress a � �� a �.\- ------------------------------------------ Installer Address d Type of Building Size Lot-_--____-__________________Sq. feet U Dwelling—No. of Bedrooms...•...................................Expansion Attic ( ) Garbage Grinder ( �l Other—T e of Building No. of persons............................ Showers — Cafeteria a' Other fixtures -------------------------------------------------------•-----•---------------------•------•-----••-----------••---------------------------•---------- d w Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacit.YJA..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 ( ) aPercolation Test Results Performed bY------------ ............................................................. Date._-----•-------------------------------- ,� Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water-._______-_____-_-___--. (14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water__--_--_-_______-------- 0 Description of Soil------------------------------------------------------------------------------------------------------------------------------------------------------------------------ X U -------------------------•-•---------•••-------...-------------•---------------------•---------------•---------•-•----------•-••----------------------------------------------------------------------- w U Nature of Repairs or Alterations—Answer when applicable.. �) ,___ /�_ �_.__ _ __.�-.._��;a.-________ . Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI 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. -------------------------------- ------� --------- �te Application Approved By. - .! ...___�/--�_ .?/. d.�L Date Application Disapproved for the following reasons:--------•--•-----------------------------------------------------•-•-••--------------------- -•--------------- ............_.......---------------•-------------------•--------•----•-----•----•--•---•------•----------------------------------•-------------------•--------------------------------•--------------- Date PermitNo......................................................... Issued------------------- .................................... Date r R THE COMMONWEALTH OF MASSACHUSETTS 5 BOARD OF HEALTH ....................................--- OF...........................--------- Appliration for Disposal Words C onstrurtiou Prrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: -------------------------------------------•------------------••---....-------•----•-••••......•. --•---------•-•-----•--•••--•••-•-•-•••...••--------•---....•----•----•------•----•----•-----••-... Location-Address or Lot No. Owner Address W q Installer Address Q Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms.............................. .. _Expansion Attic ( ) Garbage Grinder Quo) aOther—Type of Building ___________________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) Q' 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 ( ) aPercolation Test Results Performed by-•---------------•-------•-------•-•-••----•-•-......----••---•••......•. Date---------------------------------------- Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water_-.-----__-----_-..--._. �z, Test Pit No.'2................minutes per inch Depth of Test Pit________-_.-_-__---- Depth to ground water_--_.•__--_-___-____---. 01 -------------------------------------------•---•---•---•---••-•-•------•--------•---••---•......----......................................................... 0 Description of Soil------------------------------------------------------------------------------------------------------------------------------------------------------------------------ x 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 Article XI 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. gned----•--•••••---•---•----------------•--•---------•--------•----••-•-•--•----••--•----- -------------------------------- / e - -Application Approved By- - e:44_____ -- ------------------•-------------- •--...?/2�L ------------ Date Application Disapproved for the following reasons----------------------------------------------------------------------------------------------------------------- ------------------ Date PermitNo......................................................... Issued......................................................... Date THE COMMONWEALTH OF MASSACHUSETTS .�" BOARD OF HEALTH /.....? ................O F....... .................................... QuIprtif irate of Tontlrlimirr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired by..................4:5 .....------ "" --------------•-------•--------------•-------------------------------------------------------------------......----------------•----------•--. �. Install at �� - ---------------- -----`----- f --- ------------------------------------------•----------•-•----•------------------------ has been installed in accordance with the provisions of Article XI of The State Sanitary Code as described in the application for Disposal Works Construction Permit No._�_r;2 __;rS-_______________ dated.-._--.--_----___--_____-_-__-----_-----.------_ THE ISSUANCE OF THIS CERTIFICATE SMALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNC ION SATISFACTORY. DATE.................. ............................... Inspector•------ .......�..�-_r1_.`__...------------------------------------------------------. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH No. clp -9 ......................................... OF..........-------------------------------------------------------------••--....---- FEE . w ---- ---- Disposal Works 011ott.strurtiutt Vanfit Permission is hereby grant_____ .......•!".�__._ to Const ) or epair ( ) n Individual Sewage Dispos l Sy m at No........ -Z.......... ------./....:�. ., ,................. -------------•--------------------------------------------------------------- Street as shown on the application for Disposal Works Construction ermit No--------------------- Da6d------------------------------------------ ------------------------------ Bo Health DATE. --------------- V--)/&--v-------------- FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS LOCATION SEWAGE PERMIT NO. VILLAGE INST,,AlLER'S N E i ADDRESS R UILDE R OR OWNER `Z-a DATE PERMIT ISSUED .3 ` � DATE COMPLIANCE ISSUEDwlY- . �� ti a,• -6 � �' Fee No 00 �0 THE COMMONWEALTH OF MASSACHUSETTS : Entered in computer:" Yes PUBLIC HEALTH DIVISION-TOWN OF BARNSTABLE,-MASSACHUSETTS j Z[pprfcation for Migagal bpztem . Con.Oruct on Permit Application for a Permit to Construct Repair( )Upgrade( )Abandon( ) O Complete System El Individual Components Location Address or Lot No. 17 Owner's Name,Address and Tel.No. Assessor's Map/Parcel .A Installer's Name,Address,and Tel.No. pq-5-16-AC �t/. Designer's Name,Address and Tel.No. �? 13 0,4, >Z89 ;'em5-r0RZS ^0-)f Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 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) /d6'91-9C b !t-w 1 ✓ Z_/A-Is _x7Ze7V MOK25G 7Z5 g5pM f —722)/Z_' 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 provis' ns T' 5 of th nvironmental Code and not to place the system in operation until a Certifi- cate of Compliance has been ssu t B d o Health. v Signed P -ACrj Date y' O Application Approved by Date Application Disapproved for the following reaso Permit No Date Issued No. 0� ( v - Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: , Yes PUBLIC HEALTH DIVISION- TOWN"OF B,ARNSTABLEs MASSACHUSETTS �> ZippYication for 30iopaar *pgtem Con.5tructian Permit Application for a Permit to Construct(Ofepair( )Upgrade( )Abandon( ) El Complete System El Individual Components Location Address or Lot No. 317 o5rL pis, yL Owner's Name,•Address and Tel.No. Assessor's Map/Parcel , J Installer's"Name,Address,and Tel.No. Designer's Name,Address and Tel.No. ..• ? r /7A5 I�31.5 EGA✓_ E? o '13 Q X I Z 89 . j Type of Building: , Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) ` Other Type of Building No.of Persons Showers( ) Cafeteria Other Fixtures Design Flow gallons per day. Calculated daily, flow --gallons. Plan pat Number of sheets Revision Date f - Titl q Size of Septic Tank Type of S.A.S. Description of Soil F r, Nature of Repairs or Alterations(Answer when applicable) R949LgrZ 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 provisio s o Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been i sued y thi Bo of ealth. Signed 71r v 6-P-1 Date_ - G -0-9 Application Approved by Date 2 Application Disapproved for the following reasons �V } Permit No. '� J Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed ( /'Repaired( )Upgraded( ) Abandoned( )by � In at Vgn constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No dated Installer p? 3�C_AN IQ:r)NVJ _Desigw. The issuance of this permit shall not be c nstrued a a guarantee that.the system fu c 'on s designe Date Inspector .. - _. v No. Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS lwigool *p5tem Congtruction Permit Permission is hereby granted to Construct el. ( )Upgrade( )Abandon( ) System located at .3� L R; �j (Z-0 b5 l l l M.� 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:Constru tidn must be completed within three years of the date of thi t . Date:- ' Approved by d t S ,per (� !(�O �-\ COMMONWEALTH OF MASSACHUSETTS 7 EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTEC-T ON RECEIVED OCT 0 12003 TOWN OF BARNSTABLE HEALTH DEPT. TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION _ MAP �w PARCEL Property Address: 39 Eel River Rd Osterville LOr —(D-P�_ Owner's Name: Thomas Galligan Owner's Address: Date of Inspection: ,l - °u Name of Inspector:(please print) Wi 1 1 i am F_ •Robinson. Sr. Company Name: William E. Robinson Septic Service Mailing Address: P 0 Box 1089 Centerville, MA Telephone Number: ( 5081 775-8776 CERTIFICATION STATEMENT i certify that 1 have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to Se ion 15.340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: !L ' j Date: The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Heatihvr 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 approxing authority. Notes and Comments ****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. Title 5 Inspection Form 6/15/2000 page 1 t Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 39 Eel River Rd s ervi e Owner: Tlioamas a igan Date of luspectiou: Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. Sy m Passes:- I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Co ditionally Passes: One or m e system components as described in the"Conditional Pass"section need to be replaced or repaired.The syst m,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or of determined(Y,N,ND)in the for the following statements.If"not determined"please explain. The septic is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,ekhibi substantial infiltration or exfiltration or tank failure is imminent.System will pass inspection if the existing tank is eplaced with a complying septic tank as approved by the Board of Health. •A metal septi tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that a tank is less than 20 years old is available. ND explain: Observatio of sewage backup or break out or high static water level in the distribution box due to-broken or obstructed pipe(s)o due to a broken,settled or uneven distribution box.System will pass inspection if(with approval of Board o ealth): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system equired pumping more than 4 times a year due to broken or obstn.Kted 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: Page 3 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) y, Property Address: 39 Eel River Rd ` Osterville Owner: Thomas Galligan Date of inspection: 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 iling to protect public health,safety or the environment. I. System will pass unless'Board of Health determines in accordance with 310 CMR 15.303(1)(b)that they yssem 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. S stem will fail unless the Board of Health(and Public Water Supplier,if any)determines that the syste 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 s rface 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. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more front a pri ate water supply well" Method used to determine distance " his system passes if the well water analysis,performed at a DEP certified laboratory, for coliform ba teria and volatile organic compounds indicates that the well is Gee from pollution from that facility and th presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other fai a criteria are triggered. A copy of the analysis must be attached to this form. 3. ther: 3 I'agc 4 of l l OFFICIAL INSPECTION FOR AI—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 39 Eel River Rd s ervi e Owner: Th omas Gaiiigan Date of Inspection: `V� D. System Failure Criteria applicable to all systems: o must indicate"yes"or"no"to each of the following for all inspections: Yes No 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 tine 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 V3 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. 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 f^_ct from a private outer supply well with no acceptable water quality analysis. (This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that(lie well is free from pollution from that facility and (lie 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.) (Yes/No)The system fails. I have determined that one or more ofthe 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. urge Systems: To b considered a large system the system must serve a facility with a design flow of 10,000 grid to 15,000 gpd. You ust indicate either"yes"or"no"to each of the following: (llte llowing criteria apply to large systems in addition to the criteria above) yes 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 Cyou have answered"yes"to any question in Seetim E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed.The vvr-ncr c r operator of arty large system considered a ignificant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 5.304.The systern owner should contact the appropriate regional office of the Department. 4 Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 39 Eel River Rd s ervi e ` Owner: Thomas Galligan ` Date of Inspection: G� 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 1 Were any of the system components pumped out in the previous two weeks? 7— 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? t/ Was the site inspected for signs of break out? v Were all system components,excluding the SAS,located on site? -,v — 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? _ _rel4as 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: Yes no Existing information.For example,a plan at the Board of Health. Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] 5 Page 6ofII OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 39 Eel River Rd Owner: Date of Inspection: 9- G—6'3 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): 3 DESIGN flow based on 310 C7A-� .203(for example: 110 gpd x#of bedrooms): G Number of current residents:Does residence have a garbageer(yes or no):/L� Is laundry on a separate sewage system(yes or no):/.e) [if yes separate inspection required] Laundry system inspected(yes pr no):'0 Seasonal use:(yes or no): Water meter readings,if available(last 2 years usage(gpd)): 1 /1 /0 3 0 gals Sump pump(yes or no);k.0 to 7/1 /0 3 7/1 /0 2 Last date of occupancy: t 0 1 2/31 /0 2 1 0 2,0 0 0 q.4 COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 3 0 CMR 15.203): gpd Basis of design flow(se is/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holdin tank present(yes or no):_ Non-sanitary waste dis harged to the Title 5 system(yes or no):_ Water meter readings, f available: Last date of occupan /use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: �✓��6 Was system pumped as part QMc inspection(yes or no):_ If yes,volume pumped:_gallons--How was quantity pumped determined? Reason for,pumping: TYP OF SYSTEM _ OF tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool _Privy _Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank Attach a copy of the DEP approval —Other(describe): Approximate age of all components,date installed(if known)and source of irifOEM ation: Were sewage odors detected when arriving at the site(yes or no): 6 Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 39 Eel River. Rd Ostervi e Owner: Thomas Ga igan Date of inspection: —63 BUILDING SE' R(locate on site plan) Depth below grad : Materials of cons etion:_cast iron _40 PVC_other(explain): Distance from p vate water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPT IC TAI1K.,_(locate on site plan) Depth below grade: B Material of construction: ✓—concrete metal fiberglass_polyethylene —other(explain) certificate)If tank is metal list age:_ Is age con certificate) fifined•by a Certificate of Compliance(yes or no):_(attach a copy of Dimensions: � � L �d`t` �" 41 Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: I J Scum thickness: /_a Distance from top of scum to top of outlet tee or battle: Distance from bottom of scum to bottom f outlet tee or baffle: How were dimensions determined: .•— p ��/t Comments(on pumping recommendations,inlet and outlet tee or baffle conditicn,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.)-. ) GREASE T _(locate on site plan) Depth below grade: Material of construct on:_concrete metal' fiberglass_polyethylene --other (explain): — —' Dimensions: Scum thickness: Distance from top of scu .to top of outlet tee or baffle: Distance from bottom of cum to bottom of outlet tee or baffle: Date of last pumping: Continents(on pumping r commendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert, vidence of leakage,etc.): 7 Pagc 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 39 Eel River Rd s ervi e Owner: Thomas Galligan Date of inspection: = +—0 3 TIGHT or HOLD G TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade Material of constru lion: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: allons Design Flow: allons/day Alarm present(ye or no): Alarm level: Alarm in working order(yes or no): Date of last pum ing: Comments(con ition of alarm and float switches,etc.): DISTRIBUTION BOX: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): PUMP CHA119BE (locate on site plan) Pumps in wvrkin p order(yes or no): Alarms in worki order(yes or no): Comments(not condition of pump chamber,condition of pumps and appurtenances,etc.): 8 Page 9 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 39 Eel River Rd ostervttte Owner: Triomas a 19 Date of Inspection: f SOIL-ABSORPTION SYSTEM(SAS): V (Iocate on site plan,excavation not required) If SAS not located explain why: i Tali leaching pits,number: +� leaching chambers,number: leaching galleries,number: leaching trenches,number, length: leaching fields,number,dimensions: . overflow cesspool,number: innovative/altemative system Type/name of technology: Comments(note condition of soil,sigris-of hydraulic failure, level of ponding,damp soil,condition of vegetation, etc.): jv C; / S /U V CESSPOOLS: (ces ool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inle invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater' flow(yes or no): Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): PRIVY: (locate o site plan) Materials of construct' n: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): y 9 Page 10 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 39 EP 1 R i vPr Rr1 OstPrvillP Owner: Thomas Galligan Date of Inspection: ^—G�� SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet. Locate where public water supply enters the building. 3 � r 6 r Jall Q 10 Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 39 ,Eel River Rd usterville Owner. Momas GaiiiTan Date_of Inspection: SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) ✓ Accessed USGS database-explain: You must describe how you established the high ground water elevation: 11 Y 1 � 1 L F T 1. V Z A4 1/4 l i I ii S 1 13 ' 0 x 104L It- ILL n•ti - , i ' i Qm.AMJY+t. �1C11 j \V,AJP7f.':✓ ��_--- - 1 ' r r-- N 1 / aa i Oj ( /! � >~V —_ .-..� v� ' , r 4 I __—...------___ - �:_ ..�___-.--_ ._ ..-_— ----- ----. � -__.__ _-• "'.��gers5ei-�-a.••xam�-_-^-'e;�= ' ..—....�__.. .. .__...__.__ _.. .... _.... _...... .-.__ ... t _ --- - .. _ 11'' i h Q Doke: 100 . Cc�►.:c, girt<�u ' ? _ Q J -n Ile Y /CJ ' SiaY GnT G/�/ec U ar- .� t:�� t,r',e V4 IV- ! 1