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HomeMy WebLinkAbout0034 GARDINER LANE - Health JT tr "e c B 41 �I 9 1 Y µ i r 0 'r P � 1�t r Town of Barnstable P# 3� Department of Regulatory Services sArwsrns�e Public Health Division Date 1I 1 7 MASK. g. . 1639. 200 Main Street,Hyannis MA 02601 tom` ArFD MA't A , Date Scheduled % / / Time Fee Pd. ' r •m Soil Suitability Assessment for Se_ age Disposal Performed By: \O>-\tom �( �P\f�1�rC R :�• Witnessed By: LOCATION & GENERAL INFORMATION \ Location Address 3� �pRr>l>J�� L��� Owner's Name Address Assessor's Map/Parcel: ,\�,,/ 0 O Engineer's Name G O AS�faL- �(s NEW CONSTRUCTION X REPAIR- Telephone# Z�� " tms Land Use e,S Slopes(%) �> 3 Surface Stones t,a Distances from: Open Water Body 0{ ft Possible Wet Area O ft Drinking Water Well 7,p U ft Drainage Way U 0+ ft Property Line Z o �— ft Other ft SKETO:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) _ .. . lz IV g r� Parent material(geologic) G 1. QU 1 1a5 Depth to Bedrock Depth to Groundwater: Standing Water in Hole: a6 Weeping from Pit Face go Estimated Seasonal High Groundwater � yt19 DETERMINATION FOR SEASONAL HIGH WATER TABLE Method Used: Depth Observed stan ing in obs.hole: _ 110 ale in. Depth to soil mottles: in. Depth to weeping from side of obs.hole: a nC�. in. Groundwater Adjustment Z, o ft. Index Well# IIa-1r Reading Date:-1 _ 01 Index Well level �?,_l Adj.factor _ Adj.Groundwater Level PERCOLATION TEST Date 27 i. Time Observation < Hole# r t �, _ Time at 9" Ll L' L� ( S ACC /fit=( Depth of Perc �-u— �S J— �1•-1 a r,'`7 Time at 6" Start Pre-soak Time @ 0 9 Q G Time(9"-6") l� End Pre-soak %0 U ( 00 , Rate Min./Inch Z Z Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole Data To Be Completed on Back----------- ***If percolation test is to be conducted within 100' of wetland,you must first notify the ' Barnstable Conservation Division at least one(1)week prior to beginning. Q:\SEPTIC\PERC FORM.DOC DEEP OBSERVATION HOLE LOG Hole Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency,%Gravel) C-I �ar.�tCShµo I �� 1(3 ►.�o °A_ i n� DEEP OBSERVATION HOLE LOG Hole Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency,%Gravel g m 2, l�A�,Sp�o m���oin Sf�uv I LPO% . .... ... . ... .. .... . . . . . . . .. ........ ... .. .... .. . . . .. .. . . .. .. ..... .. ....:. . . ... .. ...... .. ... . .... ....... . ... . ... DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency,%Gravel IZ- - 3 0 -b��yNrl �Q — �aa�IrL. gy p(6 �i 1s 6 A0DI l.�Sr DEEP OBSERVATION HOLE LOG Hole#` Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency.%Gravel) A �oAmy Sq,1� �0��-31z 6 G I �/� ft" LOAM. 1 a (L I.�o I'(Ll P t3L� Io�R-11� % ` III 63 D L�oN- 16 A6 "� [v `Z.� t.s t `r0 a rY�rcplJm �qurJ Flood Insurance hate Man: Above 500 year flood boundary No_ Yes + Within 500 year boundary No X• Yes Within 100 year flood boundary No X Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? If not,what is the depth of naturally occurring pervious material? Certification I certify that on �`L I J (date)I hav pa t soil evaluator examination approved by the Department of nvironme tal'P otecti a th e ab ve analysis was performed by me consistent with , the required training,e ertis and p i ce 'scribe in 310 CMR 15.017. Signature Date VZO j 7 Q:\SEPTIC\PERCFORM.140C TOWN OF BARNSTABLE LOCATIOr+, v A SEWAGE # VILLAGE OQ12AAY�& ASSESS R'S MAP & LOT I)tNP60!4 NAME&PHONE N SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO. OF BEDROOMS BUILDER OIe O WNS Uh PERMITDATE: COMPLIANCE DATE: 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 /$ . � �� � a ?�'� h \� a �/� �i r q �c� �� �� , 39 , �q� OF BARNSTABLE LOCATION 7 61BI-i n2-f LAn e _ SEWAGE# 10"y la VILLAGE- (242-CV 1�'� ASSESSOR'S MAP &LOT f INSTALLER'S NAME&PHONE NO. :Tn' N J-a 10 SEPTIC TANK CAPACITY 150 0 LEACHING FACILITY: (type) S t'M i E'R,)snoS (size) '-I S X I Q NO.OF BEDROOMS BUILDER OR OWNER�t I e� PERM TDATE: g,-",1-7 COMPLIANCE DATE:_ Separation Distance Between the: Maximum Adjusted Groundwater Table and 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 facili ) 9 Feet _ Furnished by S7�i/Y61v � � G a 3 � or 5 y C 19 5 3� 6 39, y f �i- No.... . .. . Fas........ ........... THE COMMONWEALTH OF MASSACHUSETTS r � BOARD OF HEATH �/ TOWN OF BARNSTABLE Apphrativit for Bi-nVoottl Work, Tottotrnrtion amit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ..... �D�._...�..� �J /!1� .G.f/✓L- '� Y,IL = •--•----••------..........•------------•------ /'O�w i -Address or Lot No. ....� s.--•-----------------------------•----•-- ---------------------------------••---- .... j ner Address W ,1L�lfN dd.4l7... --------•--•-•------ --------••=•••-•---••--...••••-•---••----------••---••-••-•--•••-•---------Installer --•-••................� Address n Type of Building Size Lot_ rtf ______.Sq. feet ►. -Dwelling— No. of Bedrooms.--_-_-__/----------------------_----Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons...........----------------- Showers ( ) — Cafeteria ( ) a Other fixtures -------------------------------- W Design Flow.............. . f�---_.-_-_-_--_-__.-gallons per person per day. Total daily flow----- . ...........................gallons. WSeptic Tank—Liquid capacity/-5Vp_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-__----------__-_-_--.. fT Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 04 --------------------------------- -------------------------------------------------••-•......................................................... 0 Description of Soil........................................................................................................................................................................ x U -••----------••-••••-•--•••...---•-•-•------•••---------•-••-••-••-••••--•---••-•--•-----------•---••-•••--•-•--•-----------•-•---------•-•----•--•--•--••-----------•---•-•---•--------•----------•--- 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 Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance h ee issued by the-j)oard of health. jV G Sig - ® ..... _.� ....�........................... .... ...`.....�. Application,Approved B ---- - Application Disapproved for the following rea.ro - --------------------------------------------------------------------- ------- -.-......... -------------------------------- Dare Permit No. -/ - --- -------------------------- Issued ......--. / ... ............ lDare 03 /ilt A , iiii` Finc....... THE COMMONWEALTH OF MASSACHUSETTS J q BOARD OF HEALTH J� TOWN OF BARNSTABLE r liration for Diiaipoitt1 Workii Tonotrnrtion Prrmit Application is hereby made for a Permit to Construct O or Repair ( ) an Individual Sewage Disposal System at: - j ............................................................ Loc lion-:\ddress or Lot No, �Z�itT GG�4? ........... ..............................•...._..........................................................•.. Owner Address -----------------------•----- ---------- Installer Address Type of Building Size Lot. 1 .......Sq. feet U ` fi! Dwelling— No. of Bedrooms------- Expansion Attic ( ) Garbage Grinder ( ) --- - aOther—Type of Building ---------------------------- No. of persons........................... Showers ( ) — Cafeteria ( ) dOther fixtures ...............------------------------_ -..-----_------------------- -•------------- ----•------...---•--------•----------••------••.............. Design Flow_._..... ?._ U. gallons per person per day. Total daily flow..._. ._ 4__C._�'.................. W g � 'f/1- - -- g P P P Y Y f gallons. WSeptic Tank-"Liquid capacity/ 0galIons 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 :? _...__�',f � r/.l ...................... _.. Date _...._.... Test Pit No. 1----------------minutes per inch Depth of Test Pit._.--.-__---_-__-._. Depth to ground water ................._. G% 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----------------------------------------------------------------------------------------------- -------------------------- ----------------------------------------------------------------•------------•------------------------...........--------------------------------------------..........--••-- Agreement,s The uride�sig ed agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of T t, LE 5 of the State Environmental Code—The undersigned further agrees not to place the r system in operation until a Certificate of Compliance h 91 ee.; issued by the-board of health. G SI ned <l")----- G%CT g - �' ................. ..� �._.... _.. Dace?� A lication.Approved B --- ................ ------------------------------------` ..... l / ! PP PP Y - - ... ...... Application Disapproved for the following reasordt• --------------------------- . ... .............................. - ------_ - ------------ ------------------ --------...�.................... .. -Permit No. ---- - �----- ---._.. ...---. ---- Issued -----------/ �...... :. ..... .. .... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Trmtifi ak of Cfamplinure THIS IS 10 CE TIFY T ay the ndividual Sewage Disposal System constructed ( - ) or Repaired ( ) by ... r.�.h�.l'�R......../ ..L� --------------------------------------------- --- ....-------------_------------ ------------------------------------------- at ........ .... � .63_41_ 1�evllv - -a 76 /.4: ----------- - ---------------------------- has been installed in accordance with the provisions of TITLE 5 St tloyironmental Code as described in the application for Disposal Works Construction Permit No. ......._: r....... dated .....__.. BE NSTR�EID A A GUARANTEE THAT THE THE ISSUANCE OF THIS CERTIFICATE SHALL NOT CO S SYSTEM WILL FUNCTION SATISFACTORY. DATE ........ Inspects . Y- `' .... .. �., -. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH _ TOWN OF BARNSTABLE No...._._�._... FEE.-•100 ----- �i i os-1 orki� Tonitrurrtion "rrmit Permission s hereby granted---- A ;t �-------- ------------------------------------------------------------•--•--•---.. to Constru t or pair ( ) an Indi idual Sewage o Isposal S• Stet�r f at No. h� `��F� — 'I _ ✓- __... -� -e-b ................................ -•--_ �-- Street as shown on the application for Disposal Works Construction er 't No.-- _ _-----:- -- ted_ _ .................................. 7 � Boa rd�of Health DATE--- .........E^^�� . ,' ....... •-• ------------•-- s / FORM 36508 HOBBS 6 WARREN,INC.,PUBLISHERS _, a t BORTOLOTTI 'COSNSTRUCTION,,.INC. 45 INDUSTRY ROAD; MA ZSTONS MILLS, MA 026 8-� ; 0 508-771-9399 508-428-8926 FAX: 508-428-9399 °`�' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM t . PART A �, + CERTIFICATION Property Address- �7 ' Date Of Inspection O Inipector' Name: O er's Name and Address: CERTIFICATION STATEMENT: H _ I Certify that I(have personally Inspected the Sewage Disposal System at this address and that the informa- tion reported below is true,accurate and complete as of the time of Inspection:'The Inspectiolnwas'perform- ed based on my Training and Experience in the Proper Function and Maintenance of On-Site Sewage Dis- posal Systems.The system: fi M Passes Conditionally sses 4_in ?NeedsFur a valy the Local Approving Authority ' Failur Y. , } Inspector's.Signature Date: mil•«l TheSystem Inspector shall submit a opyof this Inspection Report to the Ap proving'a►uthority with Thirty (30)Days of completing this Inspection. if the System is a Shared System or has a Design Flow of 10,000 gpd or greater,,thealnspectorx and the System Owner shall submit the Report to the,appropriate Regional Offie of the Department of Environmental Protection. The Original should be sent to the System Owner:and copies sent to the,Buyer,.if,applicable and,the Approving Authority. , INSPECTIONrSUMMARY_ A) SYST. PASSES•, �, . .t•,- F�; I have not found any Information which i ndicates that the System,violates any of the fail- ure criteria as defined in 310 CMR 15.303 Any Failure Criteria not evaluated:are indi- i.cated below. ' B) SYSTEM CONDITIONALLY PASSES,f One or more System Components need to.be Replaced or Repaired;,The System,upon completion of the Replacement or Repair,Passes Inspection t 4 ; 'Indicate yes,nor,'or not determined'(Y,N,OR ND). Describe bases of determination in all histances.`If"not ` determined",explain why not. The Septic Tank is Metal,Cracked,Structurally Unsound;sliows Substantial.Infiitration or exffl tration,or Tank Failure is iimminent. The System.will Pass Inspection if Existing Septic Tank jis?Replace&with a•conforming Septic Tauk.;.as Approved by the Board Of Health. r f Sewage Backup or Breakout or High Static,W, ter Level observed in the Distribution Box is due to � Fbroken or obstructed pipe(s)or due to a broken;settled or uneven Distribution Box.'The System .will pass Inspection if(With Approval of the Board Of Health): e 1 , SUBSURFACE SEWAGE.DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Broken pipe(s)replaced "Obstruction is removed Distribution Box is levelled.or replaced The System required pumping more than four 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 ; 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 the public health,safety and the environment.. 1)SYSTEM WELL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT-FUNCTIONING IN A MANNER WHICH WILL PROTECT THE , PUBLIC HEALTH,AND SAFETY AND THE ENVIRONMENT: i 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 APPROPRIATE)DETERMINES THAT THE SYSTEM IS FUNCTION- ING .. .. .. . .... .. . ING IN A MANNER THAT.PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 Feet to a}surface water supply or tributary to.a surface water.supply. The system has a septic tank and soil absorption system and is with a Zone I of a,public water supply well. The system has a septic tank and soil absorption system and is within 50 Feet of a private water supply well. The system has a septic tank and soil absorption system and is less than 100 Feet but 50 Feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from poihition from the facility and the presence of ammonia nitrogen and nitrate nitrogen-is equal to or less than 5 ppm. D)SYSTEM'FAILS: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. :The Board of Health' should be contacted to determine what will be necessary to correct the failure. - Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. `Discharge or ponding of efluent to the surface of the ground or,surface waters due to an overloaded or clogged SAS or cesspool, ` .'Static liquid level in he distribution box above outlet invert due to;an overloaded or clog- ged SAS orc�esspool. Liquid depth in cesspool is_lessthan 0 below,invert or available volume is less than 1/2 'day flow. g r Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped { -2- I I ,� ' •" .��,d.\ �fis.I' a ' t-`--`tom T'� `+ ,i�: �_ .'� a _ '� ,+ t`r � .,..s',�c.-. ,+ •..�i�.� ., . `y SUBSURFACE SEWAGE,DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater ' elevation: Any portion of a 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 titan'100 Feet but greater than 50 Feet from a private . water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. E)LARGE SYSTEM FAILS: The following criteria apply to a_large system in addition to the criteria above: The design.flow of a system is 10,000 gpd or greater(Large System)and the system is a significant. threat to public health and safety and the environinentbecause one or more of the following' ..conditions exist:,.., x r The system is within 400 Feet o' a surface dr nkrngwater supply T = , -.. 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.''' "r The owner or operator of any such system shall bring the`systein and facility into fiill`compliance with the groundwater treatment program requirements of 314 CtWR 5.00 and 6,00:'Please consult the local regional office of the Department for further information. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Check if the following have been done: ping information was requested of the owner,occupant,and Board of Health. i. [ . None of the system components have been pumped for atleast 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 inspection. —V�•As-built plans have been obtained and examined. Note if they are not available with N/A. ; The facility or dwelling was inspected for signs of sewage back-up.. �k• _jThe system does not-receive non4anitary or industrial waste flow. ' r The site was inspected for signs of breakout. ' systein,00 ponents;excluding the Soil Absorption System;have been located on site. 'The septic tank manholes were uncovered,opened,and' the intenor of the septic tank'was`in petted for ciondition of liatlles'Or`tees,material of construction;dimensions,-depth of ligtud, depth of sludge,depth of scum. c The size and location of the Soil Absorption,System o`n the site has been determined based on , -existing information or approximated by non-intrusive methods. -3 �r.7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST(continued) e facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Subsurface Disposal System SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ... _.PART,C ... SYSTEM INFORMATION FLOW CONDITIONS RESIDENTIlt-V1 Design Flow: Ions Number of Bedrooms: Number of Current Residents:_ Garbage Grinder: Laundry Connected To System:..( Seasonal Use:/7.,e2 Water •,Meter Readings, vailable: Last-Date of Occupan CO MF.R _AI./iND 14T IAir Type`of.Establishment. Design Flow nallons/day`,-Grease Vap Present: (yes or no) Industrial Waste Holding Tank Present: r Non-Sanitary.WWaste`Discharged To The Title V System: WateuMeter..Readings,If Available:. Last Date of Occupancy: OTHER: Describe) Last Date of Occupancy: GENERAL INFORMATION PUMPING RECORDS and•souirce of information: _. System Pumped as part of inspectiOY24-- -if yes,volume pumped- 'gallons Reason for pumping: TYPE OF SYSTEM: Septic Tank/Distribution Box/Soil Absorption System Single Cesspool OverIIow Cesspool Privy Shared System(If yes,attach previous inspection records, if any) 6, Other(explain): PROXIMATE AGE pf 411 components,date installed(if known)and source of information: w Sewage odois detected when arriving at the site 41. L,y'#{ •.�1"!. b .fit 5 t3 F t f - ISyUBSURFAC_E;SEWAGE DISPOSAL SYSTEM INSPECTION FORM = ', .. PART C 1 GENERAL INFORMATION (continued) SEPTIC TANK: I/ Depth below grade: 4 Material of Construction: //concrete metal FRP Other (explain) Dimisions:� D.�''Y( 'x�, Sludge Deptli: /P ' Scum Thickness. Distance from top of sludge to bottom of outlet tee or baffle: Z$ Distance from bottom of scum to bottorn of outlet tee or baffle: y Comments:(recommendation for.pumping,condition of inlet,and outlet tees orballles;depth of liquid level in relation to inlet invert,structural integrity, vidence of le aka e, etc.) ' n ;. . GREASE TRAP Depth Below Grade: Material of Construction: concrete metal FRP Other "(explain) --. -- . 'Dimensions: Scuin Thickness: Distance from top of scum to top of outlet tee or bailie: ..... ._ Comments:(recommendation for pumping,condition of inlet;and outlet tees.or baRies;,depth:ofiiquid ,. level,in relation to"outlet invert;structural integrity' evidence of leakage ,efc:) TIGHT OR HOLDING TANK: _ Depth Below Grade: Material of Construction:=concrete_metal_FRP_Otlter(e�cplain) Dimensions: Capacity: gallons Design Flo%: >;allons/day Alarm Level: Comments: (condition of inlet tee, condition,ofalarm and,floa(switcires;;.etc.). s � , DISTRIBUTION BOX: l Depth of liquid level above outlet invert: Comments: (note if el and distribution is equal, evi nce.of solids c rryover, evidence of eakage into or out of box,etc.) „ PUMP •-,-Pum is to working Comments .(note condition•of pump chamber;condition f pump s"a`nd appurtenances,etc) 3 5 I$ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) SOIL ABSORPTION SYSTEM S M SAS (T. mte on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods) If not determined to be present,explain: Type: Leaching pits,number: Leaching chambers,number: Leaching galleries,number: Leaching trenches,number,length: Leaching fields,number,dimensions: Overflow cesspool,number: Comme ts:(note condition of�soil, si of hydraulic failure level of ponding,condition of vegetation, e(c.) T -CESSPOOLS: Number and configuration:'- --- -. Depth-top of liquid to inlet invert: K Depth of solids layer: Depth of scum layer: % Dimensions of Cesspool: Materials of construction: Indication of groundwater: Inflow(cesspool must be pumped as part of inspection) - Comments:(note condition of soilk,signs of hydraulic failure, level of ponding,condition of vegetation,. , etc.) PRiVY �/ 't Mate 'nal s of construction: Dimensions: Depth of Solids: Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation, etc.) -6- 4-SUBSURFACE SEWAGE ll1SPOSAL SYSTEM"INSPECTION FORM PART C . SYSTEM INFORMATION (continnied) SKETCH OF SEWAGE DISPOSAL SYSTEM: Include ties to atleast two permanent references, landmarks or benchmarks. Locate all wells within 100 Feet. IS h� �Ao. a 33 i f fi 1' ft tf:{✓ S at� -�v �� q aPtit14w«. A4t4a'�a� 3 ,+I DEPTH TO GROUNDWATER: / Depth to groundwater: /E/ Feel / Method of Determination or Approximation:, © eo% 7_ - '. .. - �fi`+'�a^'�srt�Hp�;;�•t•ax xa F:.��z3rs �yt,ui.�_x.,xc. - -4 I CATCH BASIN o ur > i oo_ To y�ECLAap SLOPE _ 150 �� 14-10\\ 2S0. 'ro VJRTLR)djs. UTIL/PAD — -b IL N �ZR EDGE OF PAVE ♦ e S 50'42 27 E 182.93 i Ft40 46.10' DIST/BOX �,,, ., E, W, '• ' ..4 , >. v+ �• � px'�rr// r 3 x r ..3.. {^ '� Sit c c;,. r , .'" �'ti Ft a ttG{i UllL/PAD \ wr r`� I�t F 1�O A. x u' 000 1500 GALLON PRECAST TANK coR a N Ice- H ol \ 52.680 sg.ft. \ i r � , , _— — - - �_ _ . .. �� ._ R--- - - - - - - , , f I 1 , r , ' -=- , s' 1'_ , , , II "6 s y , .� A < , i r P „ , p LY J f7 L P G U S l ' : r: I I, I, , 9 , E?.S s: 7 , , , r , BA , Y a 8 ,: a ? 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