HomeMy WebLinkAbout0091 GREAT BAY ROAD - Health 91 GREAT BAD 1D,�c ,- STERVILLE
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Town Of Barnstable IRECEIPTI
200 Main Street, Hyannis MA 02601 ' 508-862-4038
Application for Building Permit
Application No: TB-18-3635 Date Recieved: 11/1/2018
Job Location: 91 GREAT BAY ROAD,OSTERVILLE
Permit For: Building-Addition/Alteration- Residential
Contractor's Name: MARK R BOGOSIAN State Lic. No: CS-106114
Address: Falmouth, MA 02540 Applicant Phone: (774) 255-1709
(Home)Owner's Name: DAMATO, EVE& MCCARRON,EUGENE Phone: (508)740-6028
H TRS
(Home)Owner's Address: 41 OCTOBER DRIVE, FRANKLIN, MA 02038
Work Description: Remodel first floor to include kitchen cabinets,counters,tile backsplash, and patch flooring where needed.
Remodel 3 bathrooms to include new vanities,tile,and bath fixtures. Remove wall between living rooms and.
install new beam. Remove fireplace. Remove walls in kitchen area and install new structural beams per
plans.
Total Value Of Work To Be Performed: . $155,000.00
Structure Size: 0.00 0.00 0.00 l
Width Depth Total Area
I hereby swear and attest that I will require proof of workers'compensation insurance for every contractor,subcontractor,or other worker before
he/she engages in work on the above property in accordance with the Workers' Compensation Act(Chapter 568).
I understand that pursuant to 31-275 C.G.S.,officers of a corporation and partners in a partnership may elect to be excluded from coverage by
filing a waiver with the appropriate District Office;and that a sole proprietor of a business is not required to have coverage unless he files his intent to
accept coverage.
I hereby certify that I am the owner of the property which is the subject of this application or the authorized agent of the property owner and have
been authorized to make this application. I understand that when a permit is issued,it is a permit to proceed and grants no right to violate the
Massachusetts State Building Code or any other code,ordinance or statute,regardless of what might be shown or omitted on the submitted plans and
specifications. All information contained within is true and accurate to the best of my knowledge and belief.
All permits approved are subject to inspections performed by a representative of this office. Requests for inspections must be made at least 24
hours in advance.
Signed: James Bustamante 11/1/2018 (774)255-1709
Applicant Date Telephone No.
Estimated Construction Costs/Permit Fees
Total Project Cost : $155,000.00 1 Date Paid Amount Paid Check#or CC# Pay Type
Total Permit Fee: $840.50 1 11/1/2018 { $790.50 XXXX- SXXXX-XXXX- Credit Card
�� ..
Total Permit Fee Paid: $840.50 11/1/2018 $50.00 IXXXX-XXXX-XXXX- Credit Card
5637
I
4THIS IS NOT A PERMIT u
Miorandi, Donna
From: Barrows, Debi
Sent: Thursday, November 1, 2018 2:51 PM
To: Miorandi, Donna; Stepanis, Fred;Wunderly, Martin
Subject: Permit/Application:TB-18-3635 at 91 GREAT BAY ROAD, OSTERVILLE for Building -
Addition/Alteration - Residential
For your review.
Thanks,
Debi Barrows
Office Manager
Town of Barnstable
Building Department
1
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LEGEND P}�a.�7
G PROPOSED BATH VENT FAN It.,_n.,'�a.
PROPOSED HEAT DETECTOR �q
PROPOSED SMOKUCO2 DETECTOR �ahett CaRsaiu�,6
L�EXISTING WALLS
C PROPOSED WALLS
D—`DEMOLISHED WALLS
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STUDY/LIBRARY � I NotEs
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AMY S JOHN WENDELL
I - q 91 GREAT BAY RD
�I 1 OSTERVILLE.MA 02655
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I... _... I_..-. v u quMacmtE
SECOND
FLOOR PLAN-
PROPOSAL
204 D FLOOR mwEct rv�uEFR ,
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CU%Tr
TOWN OF BARNSTABLE
LOCATION SEWAGE #
VILLAGE S ASSESSOR'S MAP & LOT
j lOS j�ECTGR�S> NAME&PHONE NO. C.FJ?i,4
SEPTIC TANK CAPACITY O
LEACHING FACILITY: (type) �.�U (size r �0
,/ --�
NO.OF BEDROOMS 4f
BUILDER O O R—MZd .
PERMTTDATE: 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
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LtOrC A T ION f � SEWAGE PERMIT NO.
vex g y
VILLAGE
IIINSTA LLER'S NAME a ADDRESS
T
B UI'LDER OR OWNER
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED
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1 6) FE
THE COMMbNv�E*A
BOARD OF HEALTH
Application is hereby made for a Permit to Construct (11<®r Repair an I�df, tial Sewage Disposal
System at:
09
Location-Address or Lo
- --------a---J_i
Owner Addiess.
Siz
Dwelling—No. of Bedro
1:4 Septic Tank—Liquid capacity/Pt�.gallbps Length..4% Width....jr.......... Diameter................ D tl
Disposal Trench— Width.2,V......... Total Length--sea..."..... Total leaching area... c;��.sq. ft..
z Other Distribution box (-<* Dosing tank ( )
Percolation Test Results Performed by---6.0..o.. ..................... D ate../?/� Vv�
Test Pit No. 1�.:?�n.minutes per inch Depth of Test Pit---c6.e4e..!L Depth to ground water....
Test Pit No. 2...15�..Z-_minutes per inch Depth of Test Pit...172---------- Depth to ground water......Y
.......................... Y -1 ,e 9
ieb
The undersigne4 agrees to install the aforedescribed Individual Sewage /isposal ystem in accordance with
the provisions of TME 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Ce(rtificate of Compliance has been issuQ by, the board of health.
Date
Date 7
______
Date
| Permit No ' n"�
� .
- ^°/
t
25
No......... ..._....... Ficz...........................
THE COMMbNWERLTH OF' MASSACHUSETTS 4�"
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BOARD OF HEALTH
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Appliration for Disposal Works Tonstrurtiun 1hrmit
Application is hereby made for a"Permit to Construct Repair an Individual Sewage Disposal
System at
te-
a Location Address or Lot No. -
t ,'!ream 6'�"►//! _ i
Owner
W. ..� �': .. .
Address
--
»Installer
•.`- Address
U Type of Building Size Lot--- ' -Z-"".Sq. feet
�•, Dwelling—No. of Bedrooms__._...13._ ___ ____________Expansion Attic ( ) Garbage Grinder ( )
p4 Other—Type of Building ............................ No. of persons....................._...... Showers ( ) — Cafeteria ( )
P4Other fixtures __________________________________ _ ......_----- -----------•--------•--•• --------
• i�war
W Design Flow....... ► _..... gallons p er day. Total daily flow................ gallons.
W �' eptic Tank—Liquid capacity�'�?.gallons Length___ . ...... Width. .. Diameter................ De tli'; ..._
x Disposal Trench—NO.4' _�____ Width_,)a . ...... Total Length...9P..`..... Total leaching area.. �.sq. ft .-; ,
See e Pit No.._----•-. --.��. met r " ....._... Depth below inlet•..............•-_.. Total leaching area_ s ft
P .` P g - q - .
Z Other Distribution box ("-'' _ Dosing tank ( )
Percolation. Test Results Performed by..4 ... ��!! : !�_. . /
a Date
Test Pit No 1..��' _.minutes per inch Depth of Test Pit Depth to ground water
F 44 Test Pit No 2_.' �r'_:niinutes per inch Depth of Test Prt_ _____ Depth to ground water_-___ .::"
.�Phi -----••---._ , w..._•---••--
O Description of Soil' '" t!:. .. ?! 1. -- ...4' w±,7!�/-s � J, i
\
V w V V
U Nature of Repairs or Alterat ns Ans r when applicabl ••...
--
///yyy . ,....................................•--•-•••-- •�� - __ fffjyy..'^'_—' • A
--7" ----------------------
Agreement: ,
The,undersigned agrees to install the aforedescribed Individual Sewage Disposal ystem in accordance with
the provisions of TILT- 5 of the State Sanitary Code— The undersigned further agrees not to place the system',in.
operation until a Certificate of Compliance ha's been iss '''d b the board of health.
f ate
Application Approved By............. r% =le l .......-•----
c Dr
Application Disapproved for the following reasons: __•..... ......... .......................................•____._ ...__. ...ate ....._.. . {
a:
x Date
Permit No.............•-- r,;� Issued
......•. -•-----•-- .................---•--
f Date
_ .
TH E COMMONWEALTH
M NWEA LTH OF MASSACHUSETTS
BOARD
OF EALTH.
r
........... ...........OF.:.. ...... "�-...:.........................
Tntif irate of Bunt hata
T I CER; F ,AThat the In u' idual ew1"e Dispos Sys cons te• -' or Repaired
bye, f In 1.
rat �Y' a -sr•- ... ... ............................
,✓ has tieeri installed in accordance with the, rovi's`ioiis,of T '�L� ` T e State anitary Code as described in the
1' "`DYS osal Works Construction Permit �o.• �'-
application for4 �. p T ' '--
•---- dated- ...
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE T AT THE
SYSTEM WILL FUNCTION SATISFACTORY.
fDATE... ........................................ Inspector................._.._ .............................................................
THE COMMONWEALTH OF MASSACHUSETTS
i. BOARD OF;r- EALTH %
r . C.�
" No... <.... oF................ .... .. .....................
-. ...
EE
....
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I� nrtua ,�, rrr 1
Permission s hereby granted_.._.__..__ r �-. _-_:
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to Construct r,I�.epair ) an id ewagefDis sal Syem
;L�: . .
at No. ................
: ... : .
i
Street �- ...............
as shown on the application for Disposal Works Construction P•erii�it ated....
Board of Health
-.......... t
7r
. DATE.............° .. :..... 5
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FORM 1255 HOBBS & WARREN: INC.. PUBLISHERS, ;
1.., '�t'• ,=f`y:. .•at ' "as 1, '6.
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B4ORTOLOTTI+CONSTRUCTION, INC�� rB 2OO^
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v ...,45:INDUSTRY ROAD,MARSTONS MILLS,MA 02648
508-771-9399 508-428-8926 FAX: 508-428-9399 '
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM''
PART A
:,,CERTIFICATION - 3
Property Address:
Date Of Inspection 5 Ins ector's Name:
O er's Name and
' CERTIFICATION STATEMENT v `
I Certifythat I have 'rsonall Ins ected the Sewag a PIs osal a his a e S st m at t ddress and that theinforma-
��, : ;P.. .,.. ....Y P,.. ,,, ..,,., gig,-, .p Y
tion reported below is true,accurate and.complete:as of;the time of Inspection'The Inspectioin was perform-
as,
ed based on my Training and Experience in the,ProperFunction and Maintenance of On Site Sewage Dis-'
posal Systems T system
Passes
Needs F t .Ev ti By;the Local'Approving Authority •
Fail ._ • , >, �
Inspector's;5ignature Date:
TheSystem.Inspectorshallsubmit a copy,of this Inspection Report to.the Approving Authoritywwith Thirty
(30)Days of completing this Inspection. If the System is a Shared System or1as a Design Flow of 10,000 gpd
or greater.;:the;Inspector;and(be,System.Owner{shallsubmit,the Reportao the appropriate,ftegional Offie of
the Department;of Environmental Protection..The Original should be sent to,the System Owner and copies..
sent to tho'Buyer,xif}applicable and,;the,App.roving'Authority ,,;:, ,:: , ,._•, s
INSPECTIOM SUMMARY R
A) SYSTE PASSES::;' rf ¢>4 : £:., . . ;,r _, >,: >x= ,,, •` �.
I have not found any Information which 1 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-
�`cated.below:°`.,•s"i,,�r gin;=::F <,.r:, _ , ,'.�::;,1•P ;..p i, t•,..,.. �.r.F t _
r B) SYSffEM'CONDITIONAI.LY�'PASSES.
One or more System Components need to be'Replaced or Repaired.'The System,upon
completion of the Replacement`o'Repair,Passes'Inspection'. ''#
rya `
q' ti,
Indicate yes,nor,or'not determined(Y,N,OR NI)) Describe bases of determination m all instances..If"not.
` 4 determined",.explain why not t ;,.
s x The Septic Tank is Metal;Cracked,'Structurally Unsound,rshows Substantial Infiltration or exfil-
n ru � ik
�tration,or Tank Failure is iimminent. 1 he System will Pass'Inspectionkif Existing Septic Tank
4 =' is Replaced with a conforming Septic Tank`,as Approved by the Board O.f Health ` §_
r f� Sewage Backup or Breakout or High Static Water Level observed in the Dlstribution Box is due to
::,.. " 7ik r's'nt t, tl°. .. ♦j a, r i..ilk
t - t;.
broken or obstructed'pipe(s)or due to a broi. en,settled or uneven Distrilbution Box: The System.
will pass Inspection if(With Approval of the Board Of Health):
n�,iC'ys i.A'�'.�iti"'d.;�t �: '•',3 Y ,;�� ..` ap{� '�:�& +.iG.t- &' EMS?.oJ,k,:.�?nt`r� Cwti."',is .a..> i ��_.»ra, .+0 7 t i 7s w- 1 J.,
fir`,.' +y,�'.f-«"
��'} C'�it"�4..��f'S•'� �K�i"... arV r,4w���aM���#� 4��,r��-y�c',�`+ia�Y'�-�41,Kw s'�` �'�;:. '1yR �R; ��f.r�e.w�Y'�'�y.; � - �,F.,- ..e , 'r
vi 9�4•��� 1 .:n�x «. :f: ��.-s,a i 'i J. � > `,R,. P,.�� ! � �,
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
q
PART A
y`?' ,,;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):
Broke :pipe are replaced i
Obstruction'is removed i
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,enyironment.
,t�,i)iSYS,TEM WILL PASS'UNLESS BOARDTOF HEALTH DETERMINES THAT THE,
x�SYS M I& OT.;FUNCTIONING W.,A MANNER:WHICH WILL PROTECT THE,
PUBL,iei :ALTH AND SAFETY AND,THE ENVIRONMENT:
f
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 WELL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC.WATER
SUPPLIER,IF:APPROPRIATE DETERMINES THAT.THE SYSTEM IS TUNCTION-
-.)
ING IN A MANNER THATPROTECT'THE PUBLIC,HEALTH AND`3AFETY AND-THE
_,,ENVIRONMENT* �
The system has`a�sept''tank and soil absorption system and is within;100 Feet to&surface+`'
water.supply or tributary to a surface water supply. `
" ,The system'has xa septic tank and so►l absorption system and is with a'Zone I of a°public
>, 1 xa •4 a a p:j ._ n,., r i`��! ,y.gA'. 't+ ry LAY
water supply-well
The system has a septic tank and soil absorption system and''is within SO Feet of a`private'1.1
water supply'aell,
77
The system has a septic tank and soil absorption`system and is'less than:100 Feetbut 50-ix, Fr lbP
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 pollutionfrotul,01.;
the facility)and the presence,of ammonia nitrogen and nitrate nitrogen is equal to,oraless`: ,
sti ,_; ;, +y: thait.51ppm -
WSYSiL'1>I[FAILS:4 ! vy= 1' 9 h a II+ xlF,z'.7 y i s rr•a
I have determined that the system violates one or more of the following failure criteria as,defined
in 310 CMR 45 303. The basis for this determination.-is identified<below;'~The Board o€He$ltlt< s
r�>R$ , should be cpntacted,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.
a
Dischargeottponding of,efluent to the surface of
;the grou4id�or surface waters du,?to an !
p. +
overloaded or clogged SAS or cess 1
gg P�
Static llqutd level in;the distribution
t
box above outlet invert due to an overloaded or clog
"...
:zged SAS or cess�yo1
� dS - C"�..';�a a a i -'
Liquid depti in cesspool is less than 6"below invert or available volume is less than 1/2
.,a rill .ariGiq t1t111�1.1 i i a? e Y+?a
aired um m more than 4 times?in the last year lY 2-'L due to clogged or obstructed
i.-r.i p P p g ., c f. 7j Ny S
f pber of times pumped
ipe(s). Num
-2-
I
'� j4t;`k,J,..G �F sr- '.%i ';;�" {+I -�ti {4 �s.E•ss,;a 'xk A y n z - f`C a x+
?}'`r'u7j
'ti f 1" l: r*i t•;L3 t z s �"y s rye. ..k.:•_ a F 4-�. .y i3 "Y
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SUBSURFACE SEW_AGE'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 1.00 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 pnvy 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. 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 td the criteria above.
The design flow of a system is I0;000 gpd or greater(Large System)and the system is'a significant
threat to public health and safety and the environment because one or more of the following
conditions exist: ,
The system is within 400 Feet of a surface drinking water supply '
The system is within 206iiiet 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 public4ater"supply well: "'` `i
The owner,or operator of any such system shall bring the system and facility into full compliance with the
groundwater treatment pro gram'requirements of.314 CIWt 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
E KL T ,3
C
,
' l`r 5. }a'4.' .,t a° : ,. t. •.i`!•^ti. - .....t .,4 :- ,.'. .elf.{ `.is ! _ G++ t R Ai
Chec k if following have been done:
t ePumping information was requested of the owner,occupant,and Board of Health. 1 '
_None of the system components have been pumped for atieast two weeks and the system has >'
been receiving normal flow rates during that period. 'Large volumes of water have'not been;
V/ introduced into the system recently or as part of this inspection.
-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. -
r The system does not receive non-sanitary or industrial waste flow.:,:r.
r The site'-was:inspocted'for signs of.breakout:
All system oomponents,.exciuding the:Soil.Absorption System,have.been located on site ;
The septic tank manholes were'uncovered,'opened;and tlie'interior of the'septic tank was Yn-
". spected for condition of baffles or tees,material of construction,dimensions,deptit`of liquid, t
:.,/depth.of sludge,.depth of scum. e' 4 4'. . .,.. r ,,=
V The size and location of the Soil Absorption'Systein on the site has been determined based on
existing information or approximated by non-intrusive methods.
-3-
ci.;mf�'r�55'A�'t., a rft'i�q 'gtrr.rj}t},c,pw 'k.r i±F rimy aid} t rh�K'.c4i 'r`.Ni.,:F a 1} * ? d,0tl
,t �ry.m� n¢r6�r,�.Y✓r,ea •rt?*�3Piy,
SUBSURFACE SEWAG&bi8POSAL SYSTEM,INSPECTION FORM
PART B
CHECKLIST(continued)
10 The 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
RESIDRNTIAi.' /J /'
Design Flow: gallons Number of Bedrooms: 7 Nu r of Current Residentsb
Garbage Grinder: Laundry Connected To System Seasonal Use:
.Water,Meter,Readin if Wail able: C1j .
Last Date of Occu
CO MFR AIAND 1ST UL
:
Type of Establishment•..
-Design Flow + aallons/day�'"Grease Trap Present:(yes or no)
Industrial Waste Holding Tank Present::
..Non-Sanitary,Waste;Discharged To The Title V.System:
Water Meter Readings,If Available:? Last Date of Occupancy:
OTHER: Describe)
Lust Date of Occupancy
GENERAL INFORMATION
PUMPING RECORDS.and source of information:
System Pumped as part of inspection If yes,volu pumped: Ions
Reason for pumping:
TYPE OFSYSTEM: , e ;s
Septic Tank/Distribution Box/Soil Absorption System
Single Cesspool
Overflow Cesspool
Privy ,
ZhMroSystem(If s,attach previous inspection records if
d
ther.(explain):. S/g�r
APPROXIMATE-AGE of affcomponent$i date installed(if known)and source of.1 tnformatton.
--•Sewa odors detected when arriving at the site:
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ar�
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r« h, :+jY�ye73r d5.1�;¢ ,'�`.,�. ` �" sw r .�"'kr '':rr' .wfft
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SUBSURFACE SEWAGE U18110SAL;SYSTEMhINSPECTION FORM
`i'ART C
,•.., , GENERAt.;INFORMATION (continued)
SEPTIC TANK: ^„
Depth below grade Material of Constnictioii ✓concrete metal FRP Other
Ditntslons: ' Sludge Depth: /31.�r Scum Thickness:
Dig q;;from:top of sludge.to bottom of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Comments:,(recommendation for pumping,condition of inlet and outlet tees or baf)les,dep4h of 'quid ..•
,
level In relation"lpoutlet invert;'structural'integrity;` vidence'of leaks etch Q,
i
Depth"Below Grade! Material or Construction: concrete—" metal . t FRP Other
(explain) -- I.
Dimensions; 'Scinn Thickness:
Distance from top of scum to top of outlet tee or baffle:
Comments:(recommendation for pumping',conditiiI on of inlet and outlet tees o ;baffles,depth.of ligwd
level in.relation,to outlet invert tstructuralIntegn y eyidenee,ofaeakage;etc.)•''}
.y.
TIGHT ORMOLDING TAN _ -
Depth Below Grade: Material of Construction concrete_metal_FRP_Other(wd)lain)
Dimensions: Capacity:. g,,���,tis 'Design Flow: aailonsr� ►y
Alarm Level:
Comments: (condition of inlet.tee,condition of alarm a'id foat_switches,etc.)
x
,it t�"
DIS'I'MIMON,.BOX:
DepW of liqu►d level above.outiet invert: "
C=Rents;..(note if level.and distribution is equal,ew idence of solids carryover;evidence of leakage into
or out of box,etc.)
4.7
4 �E PUMP
y ..--Pump is in"woliin rde6 r: .
g..
Comments:'(note condition-of pump chamber,-conditi vi'of pumps and-appurtenances,etc.)
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yf 'd�• �, i
. .. SUBSURFACE'SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
SOIL ABSORPTIOYV STEM(SAS): ✓ ,
(L.ocate on site'plan,if possible;excavation not required,but may be approximated by non-intrusive .` 10
methods) If not determined to be present,explain:
.L4 ching pits,µnumber Leaching chambers,number:Leaching galleries,'number
trenches,qumber,;length:
Lea04g`5elds;,number,dimensions: ! a
Overflow cesspool,`number:
Comme ts.(note eondit n of sooi�il,,,ssigns hydraulic failure level of ponding,condition o vegetation,
.) AGO- /D"
CESSPOOLS: '
N -`'r nti n• f h role invert:umbe and'co do Depth-(op. liquid to t
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: tt yrfir 7 a¢ frte.i
Mate s of construction: Dimensions: °
Depth of Solids:
Comments (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,
i
s
vt -6-
r
b fl`
';SUBSURFACE SEW,AGE`DISPOSAL:SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
SKETCH OF SEWAGE DISPOSAL SYSTEM:
Include ties to atleast two permanent references, landmarks or benchmarks..
Locate all wells with: 100 Feet.
r�
LP
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<y�
DEPTH TO GROUNDWATER:
Depth to groundwater: /Z Feet"
bletho of Determination or pro 'mation:
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GEORGE
ARTHUR -g 5 SHOD/A,/ 7-
LOW,
IR GIFFORD
G No.603
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