HomeMy WebLinkAbout0033 FIRST AVENUE - Health 33 First Avenue 1
Osterville
I' A — 116 050
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TOWN OF BARNSTABLE
33 FIRST.AVENUE, OSTERVILLE 2003-272
LOCATION SEWAGE #
VILLAGE OSTERVILLE ASSESSOR'S MAP & LOT 116/50
INSTALLER'S NAME&PHONE NO. FI I T C BROTHERS CONST. CO. 508-362-6237
SEPTIC TANK CAPACITY i l'�o D
LEACHING FACILITY: (type) bFo6 CL• a v,S (size)
NO. OF BEDROOMS
BUILDER OR OWNER ED & .TAMMY COUTURE
PERMIT DATE: 6/18/03 COMPLIANCE DATE: /
w Separation Distance Between the:
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
within 300 feet of leaching facility) Feet
Furnished by
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No.
Fee t �
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
ZippYfcation for )Di5p0af *p5tem Construction Permit
Application for a Permit to Construct( . )Repair( )Upgrade( )Abandon( ) ❑Complete System D Individual Components
Location Address or Lot No. 1 Owner's Name,Address and Tel. o. �� S qn.«� �G
33 J k"10 so&- -737- 3V cvl(l,,`,',/J
Assessor's Map/Parcel I I D
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
11 t CC4.T
Type of Building:
Dwelling No.of Bedrooms 3 _ 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 336 �l acc��(2(a� 119 gallons.
Plan Date �w► A-9 . aGa3 Number of sheets I Revision Date
Title
Size of Septic Tank Type of S.A S. 3 's-0 G W W-e bL
a - Sdaro J 4 07
Description of Soil
Nature of Repairs or Alterations(Answer when applica e 4
Date last inspected:
Agreement:
The undersigned4thfol
the onstruction and m ' enance of the afore described on-site sewage disposal system
in accordance with the of the Env' m tal Code and not to place the system in operation until a Certifi-
cate of Compliance hathis Boazd ea -= J
S Date
Application Approved Date 6
Application Disapproing reasons
Permit No. U J 3—.2-2a Date Issued M 0
y re._
'0 0o 3 V 914 1
,.,...._No: ",. Fee
~' THE COMMONWEALTH OF MASSACHUSETTS Entered incomputer:
t --�"-- —14 ; " Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
21pprication for Migpog41}*p!5tem Construction Permit
f
Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ,❑Complete System ❑Individual Components
Location Address or Lot No. 05- Owner's Name,Address and Tel. o`�_�� 5 f r.� ('C j�t
Assessor's Map/Parcel
Installer's Name,Address,and Tel.No. 3 a ] Designer's Name,Address and Tel.No.
s-r A 611 t 1 G�-+f r-y i M 4j r,_ /� c �,� rr vt °'�
Type of Building:
Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( )`
- i Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow,' gallons per day. Calculated daily flow 33// Z rC gallons..
Plan Date 1i a 5 9 c-c 3 Number of sheets ► Revision Date
Title '
Size of Septic Tank 1.500 Type of S.A.S. 3 SU
Description of Soil
Nature of Repairs or Alterations(Answer when app a e
Date last inspected:
Agreement:
The undersigned agre4enst�heonstruction and m ' Penance of the afore described on-site sewage disposal system
in accordance with the provf the Env n tal Code and not to place the system in operation until a Certifi-
cate of Compliance has b eo Sign DateIApplicationApprove t� Date
Application Disapproved for th fol wing reasons
r
Permit No. D U 0?-2-72- Date Issued W I o S
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
5
THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired ( )Upgraded
Abandoned( )by ( I I.5 (3 C 1 i`',f CC n S/ .
at 33 F, t /g v-P n ✓ G�Je( V, << `'I has been constructed •n accordance -
with the provisions of Title 5 and the for Disposal System Co struction Permit No.�dd 3 '�72 dated I f( 0
Installer ( 1 I 6 c 0� (S Cc h.S} ` Cc . Designer "
"'"""The issuance of this)permit shall not be construed as a guarantee that the system f - io ne
Date 5 03 Inspector
5
d
- No. o 3 Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
53
}
xuiopogar 6pelem Construction Permit
Permission is hereby granted to Construct( )Repair( )Upgrade( )Abandon( )
System located at 3 E r S J- / i-•Q 4 y ( C C l+°F I/
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 within three years of the date of this permQit.
Date-_ >� Approved by
5/25/01
Notice: This Form Is To Be Used For the Repair Of Failed
Septic Systems Only
PERCOLATION TEST AND SOIL EVALUATION EXEMPTION FORM
I, DAAJ K/® hereby certify that the engineered plan signed by me
dated concerning the property located at
33,s�i, s� �y�s a�7h�2�/��"L�' meets all of the
i
following criteria:
• This failed system is connected to a residential dwelling only. There are no commercial or
business uses associated with the dwelling.
• The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes
per inch. The applicant may use historical data to conclude this fact or may conduct
preliminary tests at the site without a health agent present.
• 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 be located no less than five feet above the
maximum adjusted groundwater table elevation. [Adjust the groundwater table using the
Frimptor method when applicable]
Please complete the following:
A) Top of Ground Surface Elevation(using GIS information)
B) G.W. Elevation Z. ,tom +adjustment for high G.W., 0
�IN OF SS
DIFFERENCE BETWEEN A'and B gcti
+ � DAME E.
BRAMAN
CIVIL N
SIGNEDZ Cr DATE: " ((o D3 No. 32686C
G/STER�O�a��
ASS/ONAL ECG\
NOTICE
Based upon the above information,a repair permit will be issued for bedrooms
maximum. No additional bedrooms are authorized in the future without engineered septic system
plans.
q:health folder:perc&mp
TOWN OF BARNSTABLE
LOCATION 33 FIRST AVENUE, OSTERVILL.E SEWAGE # 2003-272
VILLAGE OSTERVI LLE ASSESSOR'S MAP & LOT 116/50
INSTALLER'S.NAME&PHONE NO. FI I T S R0T1JFRS--CONST CO. 508-362-5237
SEPTIC TANK CAPACITY l a y
LEACHING FACILITY: (type)3„Fd6 GL• ChAm .'S (size) X 31, 3'
NO.OF BEDROOMS
BUILDER OR OWNER ED & TAMMY COUTURE
PERMITDATE:" 6/18/03 COMPLIANCE DATE:
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
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131 A/
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-\ COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL-AFFAIRS
j T DEPARTMEN OF ENVIRONMENTAL P CTION' t�
� ►
�W PARCEL
LOT
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TITLE 5 ;
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address:
L ._
Owner's Name:.
Owner's Addre / TDIyNZ
yFq�PBq� 0®�
Date of Inspection: i lawy M
Name of Inspecto (please print)
Company:Name. t3�7
Mailing Address: r
FAILED IN ON. Telephone'Number: =81' � /. c3 a9
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true, accurate and complete as of the time of 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 Section 15.340 of Title 5(310 CMR I5.000). The system:
Passes
Conditionally Passes
Needs.Further Evaluation by the Local Approving Authority .
'Fails
Inspector's Signature: Date: /7
The system inspector shall submit a copy of this inspection report to the Approving.Authority(Board of Health or
DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000
,Pd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP..The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving
authority:
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
Page 2 of 11.
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
-• ._. .^ j` "i�.',� PART A
7 CERTIFICATION (continued)
i
Property Address:
Owner.
Date of . spection: Js�
Inspection Summary: Check A,B,C;D or E/ALWAYS complete.all of Section D
A. System Passes:
1:have:not found any:information which.indicates;that any-of the-failure criteria described_in,31.0:.C-MR.
15.303 or in 310 C:MR 15.304 exist.Any failure criteria not evaluated are indicated below.
Comments:
13: System Conditionally Passes:
One or more system components as described in the"Conditional Pass" section need to be replaced or
erepaired.The system,upon completion of the replacement or repair;as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please
explain.
The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally
unsound,exhibits substantial infiltration or exfiltration ontank failure is 'imminent.System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank-will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available:
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or.
obstructed pipe(s)or due to a broken,settled or uneven distribution box.System will pass inspection if(with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than'4 times a year due to broken or obstructed pipe(s).The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
2
Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: P
the jG
Owner.
Date of ection;
C. Further Evaluation is Required by the Board.of Health:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system
is failing to protect public health, safety or the environment.
1.- -Systerti will pass unless-Boatil'of'Healt,`► deterrmines'in accordance With 310 CMR 15:303(°1)(b)that the
system is not functioning in a manner which will protect public health,safety and the environment:.
Cesspool or privy is within 50 feet of a:surface water
— Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the.Board of Health (and Public Water Supplier, if any).,:determines that the
system is functioning in a manner that protects the public health,safety and environment:
_ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of
surface water supply or tributary.to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone ].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 from a.
private water supply well". Method used to determine distance
"This system passes if the well water analysis,performed at a DEP.certified.laboratory,for coliform
bacteria 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,provided that:no other
failure criteria are triggered.A copy of the analysis must be attached to this form.
3. Other:
3 :
Page 4 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY•ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
-7- o
Property Address: d'
Owner:
Date of pection:
D. System Failure Criteria applicable to all systems:
You 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
/ cloaaed SAS or cesspool
t/ Static liquid level in the distribution box above outlet invert'due to an overloaded or clogged SAS or
/ cesspool
_ V/Liquid depth in cesspool is less than 6"below invert or available volume is less than day flow
r/ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number '
of times pumped
_ _V/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 1 of a public well.
Anyportion of a cesspool or privy is within 50 feet of a.private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a DEP certified laboratory, for 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,provided that no other failure criteria
D are triggered. A copy of the analysis must be attached to this form.]
/C AYes/No)The system fails.I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of
Health to determine what will be necessary to correctthe failure.
E. Large Systems:
To be considered a large system the system must serve a facility with a design flow of 10;000 gpd to 15,000
gPd
You.must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
— _ the system is.located in a nitrogen sensitive area(interim Wellhead Protection Area—IWPA)or a mapped
Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered
"yes'.`in Section b above the large system has failed.The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR "
15.304.The system owner should contact the appropriate regional office of the Department.
4
Pace 5ofII
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART,B
CHECKLIST
Property Address:
Owner:
Date of pection: 0'3
Check if the following have been done.You must indicate"yes"or"no"as to.each of the following:
Yes No
Pumping.information.was provided by the owner,occupant, or Board of Health
Were any of the system components pumped,out in the previous two weeks
Has the system received normal flows in the previous two week period?
_ZHave large.volumes of water been introduced to the system recently or as part of this inspection?
t1— Were as built plans of the system obtained and examined?(If they were not available note as N/A)
Z/ _ Was the facility or dwelling inspected for signs of sewage back up?
V _ Was the site inspected for signs of break out
V, Were all system components, excluding the SAS, located on site
Were the septic tank manholes uncovered,opened, and the interior of the tank inspected for the condition
of the baffles or tees,material of construction, dimensions,depth of liquid,depth,of sludge and depth of scum?
Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on;
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 Cis at issue approximation of distance
is unacceptable) [310 CMR,I5302(3)(b)]
5
Page.6 of l l
OFFICIAL INSPECTION FORIM, -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:
Owner: C� ,
Date of ection:
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design):--a Number of bedrooms(actual):
DESIGN flow based on.310 CIv11 15.203 (for example: 110 gpd x#of bedrooms):
Number of current residents: �,
Does residence have a garbage grinder(yes or nQl �
Is laundry on a separate sewage system, (yes or o): [if yes separate inspection required]
Laundry system inspected(yes or no . a--
Seasonal use: (yes or no) 9- .
Water meter readings, if available(last 2 years usage(gpd)):
Sump pump(yes or n°);-,U
Last date of occupancy:
COMMERCIAL/INDUSTRIAIAit-
Type of establishment:
Design flow'(based on 310 CMR 15.203): gpd
Basis of design flow.(seats/persons/sgft,etc):
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 readincs, if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records ti
Source of information:
Was system pumped as part of the inspecti (yes or no ,o-
If yes,volume pumped: gallons--How was quantity pumped determined?
Reason'for pumping:
TYPE OF SYSTEM
Septic tank, distribution box,soil absorption system
_Single cesspool
_Overflow cesspool
Privy
_Shared system (yes or no)(if yes,.attach previous inspection records, if any)
_Innovative/Alternative technology,Attach a copy of the current operation and maintenance contract(to be
obtained froth system owner)
_Tight tank _Attach a,copy of the DEP approval
/�Other`(describe)'--. ZZQ& 6`)r E' 6,11 9 • aU Q, 126�
Approximate age of all components, date installed(if known)and source of information:.
Were:sewage odors detected when arriving at the site(yes or n
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: 4
Owner:
Date of ection
BUILDING SEWER(locate on site plan)`
Depth below grade:
Materials of construction:—cast iron 40 PVC other(explain):
Distance from private water supply well or suction line
Comments-(on condition of joints,venting,evidence of leakage, etc.):
SEPTIC.TANK-(locate on site plan)
Depth below grade:
Material of construction:—concrete metal—fiberglass` polyethylene
—other(explain)
If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of
certificate)
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:
How were dimensions determined:
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage, etc.):
GREASE TRAP: ocate on site plan)
Depth below grade:
Material of construction: concrete metal—fiberglass Polyethylene_other
(explain):
Dimensions:
Scum.thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or.baffle:
Date of last pumping:
Comments(on pumping recommendations, inlet and outlet tee or.baffle condition, structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
7
Page 8 of 11
OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY.ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owners 114-1
Date of. spection: �oo
TIGHT or HOLDING TAN]�-�tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction:- concrete metal fiberglass_polyethylene other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons/day
-Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):.
Date of last pumping:
Comments(condition 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 CHAMBER: 'locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber, condition of pumps and appurtenances,etc.):
8
Page 9 of 11
OFFICIAL INSPECTION FORM NOT:FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART`C
SYSTEM.INFORMATION(continued)
Property Address: � 0
AJA
Owner:
Date of I ection:
SOIL ABSORPTION SYSTEM(SAS):_(locate on site plan,excavation not required)
If SAS not located.explain why:
Type
leaching pits,number:_
leaching chambers,number:
leaching galleries,-number:
leaching trenches,number,length:
leaching fields,number, dimensions:
overflow cesspool,number:.
_innovative/alternative.system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure, level of ponding, damp soil,condition of vegetation,
CESSPOOLS: ,� (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth'-top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:—6"x
Indication.of.groundwater inflow(yes or no)L, ,�&[
mments(note condition of soil, signs.ofhydraulic failure,level of ponding, co dition of vegetation etc.):
(� /GO Yew2 JZee. -eo /� ` :hJ�/�Ccof
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.):
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: 33, due.
� —
Owner
Date of spertion: 9/ a003
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.
w P
' 10 .
Page I I of 11.
OFFICIAL.INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: d P
Owner:
Date of I ection. 00
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water O 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:
h
Permit Number: Date:
Completed by:
HIGH GROUND-WATER LEVEL COMPUTATION
Site Location: �33 1—rf4a,)r e7i ee- �-���lC Lot No.
Owner: Address:
Contractor: odd Address:
Notes: ;/"� �✓` �i� .sue//! /�
STEP 1 Measure depth to water table to 171
nearest 1 L10 ft. ..................... .. �LU
. .............. . ......... ......... ........... .Date
month/day/year
STEP 2 Using Water-Level Range Zone
and Index Well Map locate
site and determine: h
Appropriate index well........1....... .........
OA
OWater-level range zone ..... ......... ......... ....::...
STEP 3 Using monthly report"Current
Water Resources Conditions"
determine current depth to
water level for index well.....:.....................
month/year.
STEP 4 Using.Table of Water-level Adjustments
for index well (STEP 2A), current depth
to waterlevel for index well (STEP 3),
and water-level zone (STEP 26)
determine water-level adjustment............................................ . ................ . ........ ...........
STEP 5 Estimate depth to high water
by subtracting the water
level adjustment (STEP 4)
from measured depth to water - �!
levelat site (STEP 1) ............................................................................................................. `T
Figure 13.--Reproducible computation form.
15
J
\jq:
PfZO 3 �'LE: NOT 1-0o SALE _ TEsT I-f0LE LOB
EL- ,c g FIR5T PIPE LENGTH OVER%OFI I/2"DOUDi_E
TOP rGt�f>,I�TON COVER5 TO MTHIN To bE sET LEVEL w�srtEDsroNE DATE: - Z�-a3
b' Cr rMlsrT 6RI1DE TOR MIN. Z' TEST�Y:_ .�
- FINISH ewrz WETNESS:
s >: PER(,RATE:C z Mir//N
LL h
Y'
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wrroM ® EL Z
ar,0 .- Z. �. r rrrr 05T. Chi(
v C OA-LON SEPARATION
lJ� 7 SEPTIC TAW
4" STONC DASF-
277.j.
/3z" w�a>cic Z/,o
DE5 ION DATA 94VLJ s .9 xJ 7- w-lq;;IEF/z
DAILY FLOW: (3)150ROOMS xl 0 GPD
3.3o GPD
SEPTL TANK:330 GPD 4.001=(a40&PD
UsE:/ScoGALLON PRECAST SEPTC TANK
LEACHING FACILITY: ,
USE: ic3)-S'ic,R,sX z
CAPACITY:
SIDEWALL:-.BS X z X o,7�= /zS, 8
�o>-,-o►�+ - 9-��3 SX o,�y= z z3, i GENERAL NOTLs
TOTAL:
l CONTRACTOR TO f5E RESPONS15LE FOR THE LOCA70NOF ALL UT-UrES,
ADOVE AND UNDERGROUND,PRYER TO ANY EXCAVAT 12N OR CONSTRLV TON.
2. SEPTC SYSTEM TO�,E NSTALLEP N COMPLIANCE WITH 3{9 6-MR PDO:TITLE V
t , ✓ i_/'I`v ->�•jv , L/ ���.: •_ f :o i'~ , �-,.-� .IVY.?.j�� �I��YIiI/11 ;/(\I I�
l 2 4. tip v I L' .I�I_j?AREAT,70
5. CONTRACTOR TO PROVPE 24 HOUR NOTCE FOR ANY REgUREP N5PE6T0N5
its �
2 I 000
% ,,,„✓
M �
/G Zso S±
_ T �3EVVAOE BEAN
LOCATION:�3 3
syfvem w
1 PREPARED FOR C,O �9�-1.� G�v -r'✓Jz�
SCALE: PRAWN 15Y:
JOf5 NLWf-R: PAT Z,9 Z00 3 1EEr:
�NOFMyss� 3-O�y _--S -� --
DANIEL E Wff-LLFR
A�5�500
CIVIL N�'
No ss Q I6A•5 FALM0JRl RD N 5UITE AG GENTERVILLE, MA OZ(on
GISTS
�sSIONAL EEC' TEL.: (505) 775-0735 ti FAX: (505) 775-0754
-l�-03 PROFESSIONAL ENGINEERS & LAND SURVEYORS