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HomeMy WebLinkAbout0010 FOX HOLLOW LANE - Health 10 Fox Hollow Lane, Osterville A = I It L, n e No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 4plitation for Mispo8ar 6pstem Construction 3permit Application for a Permit to Construct( ) Repair(K Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. j O Fo.X 14o l/o w Owner's Name,Address,and Tel.No. Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's N e,Address,and Tel.No. �i C4402d G � s o!? 31.7 ) 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(min.required) gpd Design flow provided gpd Plan Date °2' .S" C 2� Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairsor Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Boar of Health. Signed Date 4`'t '- *Ze2Z Application Approved by Date -1 Application Disapproved by Date for the following reasons Permit No. ;A 50 Date Issued No. Fee / t 4 v THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN;OF BARNSTABLE, .MASSACHUSETTS Yes ftplication for Disposal Opstrut Construction Permit Application for a Permit to Construct( ) Repair Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components x Location Address or Lot No: p F-0 X 14 01/o W Owner's Name,Address,and Tel.No. Assessor's Ma /Parcel. Ca y7 C2 u l i ` ✓YI�b �r'run c� r C ��.� p l'fS bo (�+ — Gan Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. 3167 Type of Building: p `D"welling `No.of Bedrooms A,/ f'1 Lot Size sq.ft. Garbage Grinder Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures , ,, A Design Flow(min.required) gpd Design flow provided AI /f-- gpd Plan Date *2" 157— '2 Number of sheets " Revision Date Title Size of Septic Tank, Type of S.A.S:. Description of Soil ti y Nature of Repairs or Alterations(Answer when applicable) y\ �'j y Date last inspected: ( C, -Z 0 •L 2_ . lAk. Agreement: ' . The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the:provisions ofTitle-5 of the Environmental;Code..and not to puce the system in operation until a.Certificate of Compliance has been issued by this Board of Health. ' - Signed 1 Date Application Approved by r�.e� ,Y � ��.d�. ,, r ''' ,r Date �•7 �!� -) Application Disapproved by W O l P Date for the following reasons �. Permit No. ;�L 0 Date Issued,"41 ---------------- THE COMMONWEALTH OF MASSACHUSETTS ' BARNSTABLE,MASSACHUSETTS, ' �1 , Certificate of-Compliance �_� � t•�r` THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(X) Upgraded , ( ) Abandoned( )by t�-1 ck"," 6Mp e v+ at I b i---le;x [ a Lj has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No., --Df3ated Installer Z,J.'k o o" CAnP-e,.&n Designer__ )V�r `� d #bedrooms !C Approved design flow ,. ` gpd The issuance of this permit shall not be construed as a guarantee that the system wjllxfunct n as designee Date (� � � Inspector - 1 No. A_Or;t.z� " /J 0 Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Bisposal 6pstem Construction Permit Permission is hereby granted to Construct( ) Repair( Upgrade( ) Abandon( )� System located at 10 P0X o ll 6"3 L.4" t�> 51 C' and as described in the above Application for Disposal System Construction Permit. The applicant recognized 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 permit. Date '� - Approved by 2/15/22,4:01 PM y ShowAsbuilt(1700X2800) ASSESSOR'S MAP NO. 44�-PARCEL U U`j LOCATION 4W SEWRGE PERMIT NO. + aeil�. VILLAGE Cs l INSTALLER'S NAME L ADDRESS n 1 m -6UI It OR 0 NErr {— �ti'7a1."t•J �a� �it Tr'�b l V V DATE PERMIT ISSUED IID �SC� DATE COMPLIANCE ISSUED 3/ .,U https://itsqldb.town.barnstable.ma.us:8431/Home/ShowAsbuilt?mp=145006005&sq=1 1/1 ASSESSORS MAP NO: -ZJ PARCEL NO.: YmRA _..... THE COMMONWEALTH OF MASSACHUSETTS B! H E A T H ... ....................OF........ �9 Q ................................ XpVftra ion for Uiopoottt Works notrnr#ion thrutit Application is hereby made for a Permit to (Construct ( or Repair ( ) an Individual Sewage Disposal _System at: _ `. - •--•--•-- ..... ....-- I _ Ut` �-- o �- - ..�. .- cal- - ----- oc dd• or -----a.2 . .... c- . � - �.�Wi z........ .. _ ( �... w ..... G __ ... nez ' d ess . �.............................. ........................... •---- ..=....................... ---------- Inst ler Add ss dType of Building Size Lot.LZ<.� :.-----Sq. fee U Dwelling—No. of Be ..... ...................Expansion Attic ( ) Garbage Grinder Other—Type of Building ..... No. of persons............................ Showers ( ) — Cafeteria ( ) a Other fixtures --------------•-•--•--_-•_-. W Design Flow.........IL..........................gallons per person per day. Total daily flow--------��-Q----••-........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 ( ) 1­4 Percolation Test Results Performed by.......................................................••---.........._... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ fT4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water-____-___-_-------.-____ P4 •-••--•••••••••••---------••-------•-•••.............••---••---....................-••...•-•-•-•••---•-•--•----••-•••....._................_..• ........... 0 Description of Soil........................................................................................................................................................................ U ------------- •--•---------- ---------- -•-----•---•-----------------••-------------------------------------•----_....... ----------------------- ..--------------------- ......----.--- W •-•--•--------- --------•---••-----•---------------••--•-•------••--••--•--•-----------...----•---------•-••-•-•---------•-•••-•---•--.._..---------•----••----••---•------••-••--••-•-•-•-----••-----•- VNature 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 JITIE 5 of the State Sanitary Code—.The undersigned further.agrees not to place the system in o ation unt' Certificate of Complianc ash s been i sue t health. G Signed �t-r- -- -------------------- D to ApplicationAppr ved By............................................ .. . ..-•••----•- ............-------•---• -:. ®...v. Date Application Disapproved for the following reasons:. .;.................................................... . .x e Date PermitNo....................................................... Issued........................................................ Date 1 THE FOLLOWING IS/ARE THE BEST IMAGES FROM POOR QUALITY ORIGINAL (S) I A , m / � IL DATA I No......................._ Fss......................... _ THE COMMONWEALTH OF MASSACHUSETTS r BARD-OF HE A LT H .......................OF..... •• ��:�if:../:/ ! Applirration for Elispooal Works Tonotrnr#ion amit Application is hereby made for a Permit to Construct ( L<or Repair ( ) an Individual Sewage Disposal System at*_ �„r,-;.re..---_...__..••^:•- _ 't;6eation-Address �_ _,.` _. ) of Lot-'No. ;\ ._.. .Owner---•`�•..... --- _-� ......... .. .Address.--•---- .......... .._...- ..... W, , r —� `t�� �. �av r'sc. lt'',A --- - l\_....... .. .........-•--- ........ l......................... Installer ` _J Address dType of Building Size Lot.Z Z....... ....Sq. feet Dwelling—No. of Bedrooms.......... 7.......................Expansion Attic ( ) Garbage Grinder Other—Type T e of Building f� '�� ` No. of persons ....................... Showers t� YP g -==----•=-=--`=-•-----=---- P ( ) — Cafeteria ( ) Aa 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. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a+ --••------•----------•-••---•-••••.....................•-•--•------.........................._----••......................................................... O Description of Soil......................................................... 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 TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in oper,ation untqj Certificate of Compliance-has been issued:by the•board.of health. Signed- ........ /. i ✓' ' ...................... / Date Application Appr ed B ..... Application Disapproved for the following reasons:�--••---•----------------•--.....----............•..------•-----------....------------....a........-••-_... .............................•--•••-•-•••••-•-•---•---•-•--••-•-••...••••-••---•-•--•••----•••--•--••............••--•-•-•........-•-•-••-•••--•-••--•-•-•-----•---••-•••--......•--•••......-•-•-••--•- Date PermitNo......................................................... Issued-...........................--------...............---.. Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH '. !! .............OF.................... 5 ..... L.... :............... (9rdifiratr of Tontpliatta THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by......:........... r�{'e: E �-- --------------.................................? ..........................._...... Ins�atler - at----•...............Lj�_ ........... ---- JJ . - -- - ------ --. has been instalLd in accordance with therovlslonsITTI LF o e State amtar Co as descrf �Ir4 �l�e< application for Disposal Works Construction Permit No. dated.............. ............................... THE ISSUANCE OF THIS CERTIFICATE SHALLOT �lDdNSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE----�� ! 31.E �— ---....--•-•-•-•------•-••----•--....------ Inspector........��................................................................... l() Too`! Peih71C-)UA I THE COMMONWEALTH OF MASSACHUSETTS QyC L© f e t�vn BOARD OF HEALTH �Q " No...�r ,� ...��.c.�..................OF........��"y.'TL"!� :............. ..?--......�afi•r•�••C� IjFE �rv .--��� �j e�� `rye -` .... Disposal Works Tonotrnrxion "permit So Permission is hereby granted............ t..� .....-•---••......................................__.... tt t� to Constru ) or Repair ( ) ankilivial-L Sewage Disposal ystem atNo...._... ..........••... ..L& ....*.�s;-•---- ..... -- -------- ..... -...... �{� Street p k }O ��U I— . ' /'t'ry t as"shown on the appli on for Disposal`Works Construction Permit No..................... D;fted.......................................... DATE..........--j. S - ---�--�. .�..�... .�` _�- -----•• -•----•-•--••------•--•--•- • � of Health ...-•----••--••---- , ...... t.. FORM 1255 A. LKIN, INC., BOSTON _GAS%G/V 0.47".4 - SIMC-LC '�:AMIL`( - 3 6Cul2ooi( 37 3 37 3V - 3�( N o Gf�IL6 fIGG G��►.1 D C'Q. � ' ~'"`—� /S 2 73* DAI L._Y ...FLov.J l 10 Y1,3 '330 P. D. Tom- 5EPT7 C- TANK = 330 x ISoy, * 495 CG.`1) . D IS PoSAL. ?tT ^- V'SE 1000� L, ZL'i720 . ' 15"0 5.F• �t 2 . S 37S Cam.P, O. ��t BoT rD M A Z- A 5o 6-F. . .So 5. F+ - -7oTA<_ CSIGt`1 42,5'- 0-- P. D. S -� 0 25 0 ToZ-A L. DA%Ly F{.ou3 = 33o G.P O. 'g (ECZColAiloN RATE : I tN 2 MtN, oQ tzSS ;. �- a: sox o• P•T w l Tb{ /'- 3��� 3Y S/ G'E.2T/F/EO PG oT pG:4�1/ b i= STo a E ,bj 0 0 3 v Li Z Ll 0 u,o-Sc�y-E. n/v ti/i17EZ 7 Tf��4T TNE�C,rc/ 7'� SHoW.f/; 4T . . .4 f/E,L�Eov G'O�fP�Y�S !,r//T�Tfi��•.S/.OE,C,/.HE B�iX7�,2€iVYE/.tiG. .dN�.SETl�/�G� .2E4v/,eENl�Nr.S.o� Tf/� ,e.EGisr�'ecl.�.vo sv.2vEya,P,� ToW.v of = :Q,v� 45, L oc.�r�•a W/T.s��iY �',�l,E ��ctiovPl.14/y ' 'An�Am. f IV T//!t lop"A., /s /SOT 13.4sEO 4:::)N.4N 1,-fl sGYif/,yE.e�GN.S.�v�vUe-lam�S/pT l�� USEp Ta E.S�3G%Sy.Lor't�iVEs; �✓b✓;:�br a� ,, ��P�,jN OF �jgss WHARD � PETER A. v SULLIVAN BAXTER - No. � Na 24043 .o 23733 s �� u �SSI AAI t E��`Cl `k w 4 ASSESSOR'S MAP NO. * PARCEL LOCATION AW SEWAGE PERMIT NO. VILLAGE < I N S T A LLER'S NAME A ADDRESS - -� -�- 1 s w LL DUI DER OR 0 NER v t- t-nu DA T E E R M I T I S S U E D IC5 � 1 DATE COMPLIANCE ISSUED `3 i ;;� ii 3! ' ,i �.�. �. '� �'y' � �.; .r - - J . \ COMMONWEALTH OF N ASSACHL•SE Or(r e)-A EXECUTIVE OFFICE OF F-\-VIR0NME� AFFMF4 `k TON, 19 _ DEPARTMENT OF EN-VIRONN E\TX ROTJF,gT,7jON 9 ONE W1NTER STREET. BOSTON. MA 0_106 Fi'•_S: %t WILLIAV F WELD TRt'D)'COX Govcmc Sc:re ARGEO PAUL CELLUCCI DAVID B STRLT Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM . Commission PART A ? CERTIFICATION �!F Property.Address: 0 l trot\Ow �'� , CQ"t"r"`o_ Address of Owner. Date of Inspection: `�b'��, Of different) Name of Inspector: H, Q o !1 E�bcc�o I am a DEP ap roved system inspector pursuant to Section 15.340 of Title 3 (310 CMR 15.000) Company Name:�/ v yr�c'c En #-8•♦ r-7.4 we p AA 4�--/ Mailing Address: 'P p /;o,c e 37?!�4 H l-5Ze eg- Telephone Number: rSG ) CERTIFICATION STATEMENT I cer,if that I have personalh inspected the sewage disposal system at this address and tha: the information reported beioN is true. accurate and complete as o:the time of inspec.o-.. The inspection was performed bases on rri training and experience to the proper funcior, and maintenance of on-sae seAage disposa• systems The system: Pastes Ccnc-t-onaii% Passes Neecs Furthe• E%•a!uat:on B% the Local Approving Autnonrti Fa Inspector's Signature: Date: The Svste^ Insoecto• shai' submr, a cop% of this inspection report to the Approving Authcrtt% within thin (30, days of completing this tnspec,00r.. It the s%sterr is a shared system or has a design flc\,% of 10,000 god or greater, the inspector and the system owner shall submit the repo-: to the noroorze regional office of the Department of Environmental Protector The crig:na! should be sent to the system ovine- and copies sent to the bu%•er, if applicable. and the approving authortty INSPECTION SUMMARY: Check A, B, C, or D: AI SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS. BI SYSTEM CONDITIONALLY PASSES: One or more system components as described in the 'Conditional Pass' section need to be replaced or repaired. The system, upor completion of the replacement or repair, as approved by the Board of Health, will pass. Indicate yes, no. or not determined (Y, N. or ND:. Describe basis of determination in all instances. If "not determined", explain why not. _ The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) 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 as approved by the Board of Health. Irev.a•d 0�/:S!f'•) Page 1 of 10 F ' e SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTIO% FORM PART A CERTIFICATION (continued) Property Address: Owner: Date of Inspection. BJ SYSTEM CONDITIONALLY PASSES icontin j-d _ Sewage backup or breakout or high static water level observed i the distribution box is due to broken or obstructed pipets) or due to a broken, settled or uneven distribution box. system will pass inspection if(with approval of-the Board of Healthi. Describe observations7 broken pipe(s) are replaced obstruction is removed distribution box is levelled or repla The system required pumping more than/ce r due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board broken pipetsi are repl obstruction is removed C] FURTHER EVALUATION IS REQUIRED BY THE BOARConditions exist which reauire further evaluation bHealth in order to determine if the system is failing to protect the public heath, saiet,• and the environment. 1) SYSTEM WILL PASS U%LES5 BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEAL/ca ND SAFETY AND THE ENVIRONMENT: Cesspool or prio, is within 50 fee: urface water Cesspoo' or privy is „ithin 50 feet ordering vegetated wetland or a salt marsh. 21 SYSTEM WILL FAIL UNLESS THE BOARD 9 F HEALTH (AND PUBLIC WATER SUPPI11M IF APPROPRIATE) DETERMINES THA. THE SYSTEM IS FUNCTIONItiG IN A MA NER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The s\•sterr has a septic tank a d sail absorption system (SAY) and the SAS is within 100 feet to a surface water supply or tributan•to a surface water su ply. The system has a septic tank nd soil absorption system and the SAS is within a Zone I of a public water sup.-)Iv well. The system has.a septic tan and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tan and soil absorption system and the SAS is less tfar. 100 fee! but 50 feet or more from a private water supply well, niess a well water analysis for coliform bacteria and volatile organic compounds indictes tha the well is free from poll tion from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Meth used to determine distance (approximation not valid). 3) OTHER (zavl.aG 0�:25/!'1 sage 2 of 10 f SUBSURFACE SEWAGE DISPOSAL SISTEM INSPECTIOti FORM PART A CERTIFICATION (continued) Property Address: Owner: Date of Inspection: DJ SYSTEM FAILS: You must indicate either "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 ef,ned in 310 CMR 15.303 The basis for this determination is identified below. The Board of Health should be contacted to termine what will be necessary to correct the failure. Yes No Backup of selvage into facile' or system component due to an overload or clogged SAS or cesspool Discharge or pond,ng of effluent to the surface of the ground /to ce waters due to an overloaded or clogged SAS or cesspool. S;a:,c heard level in the dismbj;,or, box above outlet invert d n overloaded or clogged SAS or cesspoo! l,eu,d death in cesspool ,s less than 6" beloK invert or available volume is iess than 1/2 day flog. Reowred pumping more than 4 times in the last year PLOT to clogged or obstructer pipe s Nurncer o-times pumped _. Any por,:o- o�the So!) Absorption Syste r., cesspo6! or privy is blow the high groundwater eieva;for, A o-:or. of a cesspool or /_ p pr,�� is v+;th,r: 100 feet of a surface Ovater suppiv or tribu;an to a surface wave, suppl}. An} po-,on of a cesspoo' or pri% ,s v,rthin Zone I of a public we!I. Any pc-,c- e"a cesspoo' o, pr;y: ,s n 50 fee; of a private water supple we!! Any po--o-. o:a cesspool or privy is ss than 100 feet but greater than 50 fee; from a private hater supo!y well with no acceptable Nate, qua!i,, ana)ys s li the we!I has been analyzer to be acceptable. arach cop. of well water analvs,s for coliform bacte!.a vo!a:,le organic o-•pounds, ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: lou must indicate e::he• **Yes' or "No" as to e- h of the following. The fo!ioN:ng cr,te,.a app;,. to large systems ,n addition to the criteria above. The system se-ves a facilin with design fioN of 10,000 gpd or greater (large System; and the system is a significant threat to public hea!th and safes and th environment because one or more of the following conditions exist: Yes No the system is w thin 400 feet of a surface drinking water supply _ the system i within 200 feet of a tributary to a surface drinking water supply the syste is located in a nitrogen sensitive area (Interim Wellhead Protection Area - IWPA) or a mapped Zone II of a pu/&iiR ater supply well) The owner or operato } such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 .00 and 6.00. Please consult the local regional office of the Department for further iniormation. (revised 04/25/97) Page 3 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSP ECTION FORM PART B CHECKLIST 0 Fc:x lt�l�oc,1 Propert} Addrej: `,,,, Owner: Date of Inspection: lai(16 Check if the following have been done: You must indicate etcher "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 recently or as part of this inspeciion As bull'. plans have been oo:a:ned and examined. Note if they are not available with WA The fac:lln or d%%ell,ng %%as inspected for signs o-*sewage back-up. _ The system does not receive non-sanitarn. or industrial waste flow. _ The site %%as inspected for signs of breakout _ AH systerr components. excluding the So-'. Aosorpt;on System, have been located on the site. � The sep:,c tank manho�e: v.ea uncovered. opeed v r n . and the interior of the septic tank was inspected for cond.tior of•, _ baffies or tees. mater,a' o' construction. dimensions, deptn of liquid,.depth of sludge, depth of scum. The sue and location, of the Sol' Absorption System on the site has been determined based on — The facd,t. o%.ne• ,aro occuoants. r.•d;fteren: von'. owneri were provided with information on the proper maintenance of Sub-Surfiace Disposal Svstern. 44 Ex;st;rg information Ex Plan at E O H _ Determined in the field :r an. of the failure criteria related to Part C is at issue, approximation of distance is unacceo:ab-e 113 302.3;b? (revised 04/25/57) Page 4 of 10 SL:BSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Propertv Address: J Owner: Jl, 1`G(MP lrJQ,, Date of Inspection:`��161�� 6 i BUILDING SEWER: �rJ (locate on site plan) 1 Depth below grade. Material of construction. _cast iron _40 PVC _ other texplaW Distance from private water supply well or suction I;-t Diameter Comments: (condition of joints, venting, evidence of leakage, etc.) SEPTIC TANK (locate on site plan, it Depth belo, grade 1.taterial of construction _,concrete _meta _Fiorglass _Polvethylene _other;expla n If tank ;s metal, Its: age _ Is age cor.i,rmec b% Cen.ficxe of Compliance —(tes o Dimensions � ^ Sludge depth 'l tit D;siance from top o: siuoge to bono o' outlet tee o• ba.�;;e Scum thickness ®°° I( Distance from top of scum to top o` outle: tee or bale i� Distance from bottom o; scv-^ to bo. o*—, cl outlet tee e• baT.e 1 How dimensions Here dete•m;nec Y�LciSt: Comments (recommendation for pumping rondition o� ;n;e: and o-itlet tees or baffles. depth of liquid level in relation to outlet invert, structural ° iritegn � evidence of leakage. etc ; w T I ti b GREASE TRAP: I"y (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 tee or baffle. Distance from bottom of scum to bottom of outlet tee or baffle: _ Date of last pumping Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc ; (zee•:sed 04J25.17) Page 6 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM I%SPECT1O% FOR.m PART C SYSTEM INFORMATIO% Propertm Address: 10 t'CX V6%6-3 Owner: (;Vl QZVV-p &., J Date of Inspection: 1QIIb��j 1 FLOW CONDITIONS RESIDENTIAL: Design flo%& '?,Z,Q¢p.d..rbedroom for SA.15 Number of bearooms O3 Number o'current residents Garbage g,,:der (yes or no,1J Laundry co-•^ected to system (,yes or no' Seasonal use (yes or no-.k=)L) Water meter readings. if available (last two .2 year usage tgod). tart Sump Pump (Yes or no) Las dare o occupant- ?JUtAQ ( COMMERC140-N DUSTRI AL: Type of establtshmen: Design fio%% ¢ahonsca% Grease trap presenr ryes or no_ Industria! 1%aste Holding Tani: oresen: Ives or no Non-sanita,% waste d,scnarge-- to the Taie 5 s\-stem ices or no_ 1�ater meter readings if mailable Las:Faze o: a c,-;2-,c, OTHER; .Describe Last care of occucanc, GENERAL INFORMATION PUMPING RECORDS and source of iniormation T t1 t a�2 '►r� i�s�2�c� �v� System pumpec as par, of tnspectoon: Ives or no._ If yes, volume pumped ¢allons Reason for pumping TYPE OF SYSTEM Septic tank/distribution boxrsoil absorption system Srngie cesspool Overflow cesspool P r n.), Shared system (yes or no! (if yes, attach previous inspection records, if any) I/A Technologv etc. Copy of up to date contract? Other APPROXIMATE AGE of.all components, date installed (if known) and source of information: y' Sewage odors detected when arriving at the site. (,yes or not-F-N'6 (revised 04/25/91; Page 5 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Propert. Address: (Q3 Fox k-6l(Qt-J O,ner: Sti- QbW)Alt�� Date of Inspection: ��I 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(expiain) Dimensions. Capacim gal)ons Deng f1oN galions`da. Alarm level A,a•m in %%orking order _ Yes. _ No Date of previous pumping Comments (condition of inlet tee. condition o- a'a,rr. and float switches. etc.) DISTRIBUTIO% BOXAA, iioca:e on site pan Dec:^ of Iiou!d le e' aoo•.e oune: ime^CT" c�l� Ovt(.zTSNl�4�� Corn-:e-ts incite Yle,•�e' pad 1d:sl.,�ib_�_-(�or, it eaua evidence o' solids carryover evidence of leakage mto`ornout of box, etc.) 1>—e x -An u,11; ! ����� F V 1 L iYn.2_. �]c�.l cf ♦ f�Mn a�3� C� PUMP CHAMBER: (locate on site plan. Pumps in working order: (Yes or No, Alarms in working order (Nes or No Comments. (note condition of pump chamber, condition of pumps and appurtenances, etc.) (zav:sad 04/25/97) Pago 7 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Sr, Q�V1�lc IN Date of Inspection: j 6 i (5 � SOIL ABSORPTION SYSTEM (SAS): (' p (locate on site,plan, if possible, exca,.ation 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. r.umber,length. leaching fieicis, number, di-nens,o^s ovei4low cesspool, number Alternative s%,stem Name of Tecnr,oiog� Comments. mote condition of soli. sys of hydra,,hc failure, leve': of pond. g;con 6tio of vegetation, etc., 6 ^- CESSPOOLS. l� (locate on site plar numbe• and con;,g;;ra:,o-. Deoth-top of liquid to inlet in%,er, Depth of solids lave- Depth of scum layer Dimensions of cesspoo: Materials of construction Indication of groundwate- inflow• tcesspoot must oe pumpec as par, of inspection: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: (locate on site plan) Materials of construction: Dimensions. Depth of solids: Comments (note condition of soil, s,grs of hydraulic failure, level of ponding, condition of vegetation, etc.) (revised 04/25/91) Page a of 10 . v SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM NFORMATION (continued) Property Address:` fi5x ow+d-v.D Owner: Srr tC,<ii/Vtgl�u 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) 2 3 . 3o, (zovisa: 04125!97i Dag• f of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTIO% FORM PART C SYSTEM INFORMATION (continued) Propert"' Addr s: (6Tb}Y' Owner: 5T, ' Date of Inspection:•,(tiq . Depth to Ground%ate, -419ee: Please indicate all the methods used to determine High Groundwater Elevation: Obtained irom Design Plans on record Observation of Site (Abutting properry. observation hole, basement sump etc.) Determine it from local conditions Cneck %%ith Iota' Beard o• nea!tr Chec*k FE.NAA rhos Check pumping records Check Iota! exca,ato,s irs:a!le•s use LSCS Da:a r• Descibe in pox o%•- %•.o,os ro.. %o_ es:a_;-s=ec the GroundNater Elevation. (Must be completed (loS, ��� t;Q� ���( di►e. =Nves��, c►�s� , I',� �gz Page 10 of 10