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Home My WebLink About0091 OLDHAM ROAD - Health 91 Oldham Road Osterville A 120.. 1114 ° e a , 080 .SO�.... Fps.... . .............. THE COMMONWEALTH.OF MASSACHUSETTS BOAR® -OF HEALT ...........( ..l,�J/ ..........OF.... /�IZ 1 �.. .�..- .:............ Appliration for Disposal Works Tonstrur#iun famit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at Lat —?R zkmvld......................:'_Q5ft.4.r L.N.. ............... Lo Address or Lot No .C.=� � .�../.� �,. rr z .._ ,�r/k� '--..1..� c �,u :�r�ners -------------------�-1� . ........... ...............................................................==------.....•-----------------.. Installer Address r-• Type of Building ,� Size Lot...W..6d_ .Sq. feet Dwelling—No. of Bedrooms........... ..........:...................Expansion Attic ( ) Garbage Grinder ( ) '4 Other—Type T e of Building ..... No. of persons...............yP g -------------------•--- P ---------- Showers (2!4 — Cafeteria ( ) a' 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 nk ( ) p Percolation Test Results Performed by._._: I�1 C� _._._I, _�R.... Test Pit No. 1.42.....Z.minutes per inch Depth of Test Pit.................... Depth to ground water........................ fZ4 Test Pit No. 2__.`_2._.2-.4:nnutes per inch Depth of Test Pit.................... Depth to ground water........................ a - ....... ..... •........._ --- -•-- Description of Soil---Q`�' ----- - - 1 .�.. . --•---...... --------I--.... - pll v x W UNature of Repairs or Alterations—Answer when applicable............................................................................................... ...--•••-• • •---•-•-••••-•--•-•••••-••-•-------••--•---------•---•--•-------•-..._..•-•• Agreement:The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iI'l U 5 of the State Sanitary Code—The undersigned further agrees not to place the sys m in operation until a Certificate of Compliance has been iss ed by the board of h lth. Sign t,R...t.. •-- • ..... . ............... _. Date Application Approved By= - Date ..- Z�-_ ='----- Application Disapproved for the following reasons:.......................................: ....... 9� -••-•••........-••-••--••-----•-•-----•••--•--•••-----•-••••-•----•-•--••--••-•-•-•-------...••••---•••---••---•••--••••--•-••-•-••-•-----•----•••-••---•••----••--••----••--•-•-•------•-••--•-----•--- Date PermitNo.....................:................................... Issued..................................................... Date N ......_....... FEs........................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF H E'ALT .......TO.VV_X.1..---.....OF.... f�.GU.� �� .��L......................... Appliration for Disposal Works Tonstrairtion Vprrmit Application is hereby made for a Permit to Construct ( ) 'or Repair ( ) an Individual Sewage Disposal System at: . Address Lo or Lot N Zv , i Owner Address Installer Address --v� U Type of Building Size Lot._.4W'5��. .. .Sq. feet Dwelling—No. of Bedrooms........_. --•-_--------------------Expansion Attic ( ) Garbage Grinder ( ) aa Other—T e of Building No. of ersons........_._�: YP g ---------------•--••-------- P --•-------- Showers (�..} — Cafeteria ( ) dOther fixtures ------------------------•------------------•-----------••--••--------------•-•-•--••------••----•-••-••----------------.....................-------• w Design Flow...........v...............................gallons per person per day. Total daily flow...................:.............._"......gallons. WSeptic Tank—Liquid capacity._... ....gallons Length................ Width................ Diameter----............ Depth................ xDisposal 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 ank, ( ) IH p ,) VPercolation Test Results Performed by..._ .._.L-9 ..... / -�. �✓ . .Date_ _ -........................ Test Pit No. l.e._..:Z.minutes per inch Depth of Test Pit.................... Depth to ground water.......--............--. f� Test Pit No. 2-_-!!�n.__Z-minutes per inch Depth of Test Pit.................... Depth to ground water........................ � f ----------- [ - - ,� Description of Soil--•� 1•- .. . .. .. !�I. .Qf �� 1��s..........� x w UNature of Repairs or Alterations—Answer when applicable............................................................................................... ----•---------......................... -•-----•-•-------------------------------------------•----------------------------------------.--------------------------•--------------------------------- Agreement: The undersigned agrees to install the aforedescribed. Individual Sewage Disposal System in accordance with the provisions of TITI.1"• 5 of the State Sanitary Code— The undersigned further agrees not to place the sys em in operation until a Certificate of Compliance has been iss led by the board of h lth Application Approved B Date Application Disapproved for the following reasons-.............................................---.............................................................. - --------------------------•---•---•-------------.....------------••••-••-------•--•------------......---•---......------------•----------•-----•-••--•----••--•••••--------•----••--. --•--•----------- Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS 1P.W BOARD OF HEALTH ........ ..........OF.......1 .r�?! .1.... [ >.---------------------------- Trtifiratr of TuanpliFanrr THIS IS 7-0 CER IF , That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) c' by----- ----I°1� t.� -- ` '�-:��.::. ............................................................ ----- ............................................... - has been installed in accordance with the provisions of I L`, of The State Sanitary Code as described in the "application for Disposal Works Construction Permit No......................................... dated....................--...........---............ THE ISSUANCE OF THIS CERTIFICATE'SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE......................... ................................ Inspector --- ••••-..!! ............................ THE COMMONWEALTH OF MASSACHUSETTS -,BOARD. OF HEAL H � .No......................... FEE........................ �i��rn��a nrk� nn��nr#uan rrani� Permission is hereby granted---•- QC&..A------. l_�,�c,`.. ...................................................................................... to Construct air an In ', ua_l/S_ewn a DIsjS S st ize reet as shown on the application for Disposal Works Constructio Er ... .. .-- e ....... - •......................... ------•--------------------------------------- ----- ------------------------- 1--- S.J.. ................................. Board of Healt DATE-------- ----- •----- FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS THE FOLLOWING IS/ARE THE BEST IMAGES FROM POOR QUALITY ORIGINAL (S) M7��-C&' -,L DATA r j7 ` r s �l 1 , s g fe 7 7- r {, r r a j f 7 ` r v rhU'7ttitz 3 t si J I _I v YID f , t �. S �'... 36 ,. -, •f jl t -'%/s ti I`V"..,.� _ �,.'�, --,t ,\ �J :i/S �4 ° �" 4, k��y ° :h ) wzii AA LEGEND a EXISTING 6PAT. ELEVATION -AX® - . : . CERTIFIED' PLOT° P.hAR EXISTING CON'TOUR.— — 0 FiNI:SHED SPOT ELEVATION /� L -77 .I FINISHED'' CONTOUR 0 .£`r 'APPROVE-D ! BOARD OF^ `HEALTH` IN SVASI'l DATE AGENT SCALE.B.. 1 'rr '®.ATE` LDREOGE ENGINEERING CO. IN �-- CLIENT r I CERTIFY '-THAT 'THE.;PROPE�S![6 EGISTERE REGISTERED JOB NO. BUILDING SHOWN ON: THIS PL.`/►M CIVIL LAND CONFORMS TO THE ZONING 1AM18 ENGINEER SURVEYOR DR.BY= OF BARNSr�A81E , MAS 33 NO. MAIN ST 712 MAIN ST. CH. BY SO. YARMOUTH MASS. :' HYANNIS MASS. - . .� SHEET OF IDA E R 0. LAND SURVIE I, /IP:. B lii0�'E /i`. !'7ri'✓G�Q 9'MC.KEPT/C;TAN�C OR R/T ARE MOM& THAN /2"BELOtw li ��A�,� �+0/�lI�I ET�R COI�G'RFTF COi��R -F Ape F/Pz �JNe49E� 49AP 9001-ON7* 7m 49,gA 0 W.�A/✓ •Ei1'TR.'Q MIN; A'W'" AO-"-4 iY CAST IRON CD✓arm SyA.LL EE US6�'.O e,. a L= r �;�, �NER.S /I�'/�"p � N ®Ti vff,w.4 Y. A t. m/Jv. C'O/VC.egT, a AOE CO rEfZ CLEAN .5 L ue®LEllE 4 . ...CST A • - !. Z*.LAyER �:6 /�9/N.P/Tcg+ Gs4L. • ,VIP TANX . BGX •, 4 t t e . e . • • �e , WASHED SANE 1[.: o: Q . • i °� a ,o offPee 0 er e • •'1x-. • ° � � • DEPTH • • • �. a lV.4SXED STDNE -; env �.� • • •• • e peon v. < • � . � • •-•,• • p. p PRECAST;SEEA4GE 1AWPA'T ELE1/A7*14&S' a o • • • . • all a `o P/T ,OR EQV/V. , INVERT AT OU/GD/NG; 7 o FT. G FT D/AM. INLET .SeEP'P/c T.Q}A//t T, FT. .D/Am. C(sre 7�9D!/L.4,TjO v Ol/:7LET SEP?/C T�4/V 6� yv FT /N.CET 0/VTR/8! /OeV' ®OX. GRDuNo 1tITEit TEE OVTLETO/ "174/®t/TioArr ,2 . /HLRr e.Z14CNINIG ��7- 3—T-FT uE1VAGdff /•�'�QeSAL-SYSTIM' TAQIILATIDN L 'H//VG p/T DMFN.S/ON A_ FT• DES/GN CR®TERs�I. sca I tR': %4" _ �=o" 0/MAK5/ON $ 6 FT. GA Qd.4G.ED/SPOsu�d elNlT 0�►: TGTA4.&3 7 ir � L0A6! � v SOIL TE9°T . 49.44./Aa4T SO6.4 7,657 A'/ SO//- rirS7-#,2 r NUMBER QF'4!'•4 A/B�SI is/3'�_L BLE B/ �1.�% ALAF4V, RATE StoZcE.4CH/wG-'AmjF��/� �-_, ter. : 00 rrOM 4s4CN/Na j&JR Pir. 7 b' RESI/LTS K/L7'A1&=FD dY:, , n yN �c j s Ar - ALRCo�/►7Yoir �earE ! �� s� .S'� .4` I�JlCO�T%ON RATE� �r %►� � �►;r RB?BRI�EL&4C/4l// �4REAT ✓y. SQ. FT. �ZI ::ROBERP. as 3 .- t. No.2216Z 4 t : a e ��. •-�.. may;-71�»-�+� ►�Ill �n2 • f'' T '�"I^P�i/QP+I'/7M`�",i cl.� AS�•� P� �� -� - .. r �s - .; N+,u��la"�';tF:'m.�'1,-4 iY#w�tw..'�.eiiF'1C �i: .: �• �i�". ,..... � �;n. .. . ,N,;}k...... .. i`. ��..f�,... .. ... ,. ..... ,.satt ,.. .. .. ., .. ... ..,. : .. ,. ,. .....,. �' ,..., • 4 LO SEWAGE PERMIT NO. VILLAGE INSTA LLER'S NAME i ADDRESS S U I L D E R OR OWNER DATE PERMIT ISSUED DATE COMPLIANCE ISSUED j%�g� �� , .� j 37� ,. �� id � 1 �� IIC= ' _= � = �. . �;�,. r f. i i t COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS y DEPARTMENT OF ENVIRONMENTAL P 0XEGT40xr RECEIVE® DEC 1 2 2002 TOWN OF BARNSTABLE TITLE 5 HEALTH DEPT. - OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: MAP Oldham Rd r Osterville PARCEL ' Owner's Name: Stuart Boo r LOT Owner's Address: ` Date of Inspection: �2— 6 z,- Name of Inspector:(please print) W i 1 1 i am E- Rob i n son S r. Company Name: William E. Robinson Septic Service Mailing Address: P 0 Box 1089 Centerville, MA_ Telephone Number: (5081 775-8776 CERTIFICATION STATEMENT 1 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 Zscs ion.15.340 of Title 5(310 CMR 15.000� The system: Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Da 2 te.,f, o The system inspector shall submit a copy of this.inspection report to the Approving Authority(Board of Heatthvr DEP)within 30 days of completing this inspection.If the system is a shared system or bas a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments +L,.',This-report only describes conditions at the time of inspection and under the conditions of use at that time.,This inspection,dges, not address how the system will perform in the future under the same or different h. - . . conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of l l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY SON FORM SSESSMENTS SUBSURFACE-SEWAGE DISPOSAL SYSTEM INSPECT PART A CERTIFICATION (continued) i _� ,� s•a, 1. . Property Address: 9 {. Owner. o er Date of' ' Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. Sys em Passes: l/ 1 have not found any information which indicates that any of the failure critenbea dds cribed in 310 CMR 15.303 or in 3.10 CIviR 15.304�exist.+Any failure criteria not evaluated are indicated Comments: r } ' System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or reps ed.The system,upon.complction of the replacement or repair,as approved by the Board of Health,will pass. 9 N ned(Y, ,ND) Answe yes,no or not determi in the for the following statements If"not determined"please „ .. explain. e septic tank is metal and over 20 years old*or the septic tank.(whether metal or not)is structurally unsound,exhibits substantial infiltration or cxfiltration or tank failure is immincnL'System'will 'pass inspection if the ng septic tank as approved by the Board of Health. existing is replaced with a complyi •A metal septic tank will pass'mspection if it is structurally sound,not leaking and if a Certificate of Compliance indicatin that the tank is less than 20 years old is available. ND expla O servation of sewage backup or break out or high static water level in the disL-ibution box due to'broken or obstruct pipe(s)or due to a broken,settled or uneven distribution box.System will pass inspection if(with approval f Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND ex p ain: The system-required pumping more than 4 times a year due to broken or obstr%xAcd pipe(s)-The System will pass ' spection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is=MOYcd ND cx lain: Page 3 of 11 OFFICIAL INSPECTION_FORM=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM .:PART,A, . . u CERTIFICATION(continued), Property Address:' 91 Oldham Rd r :a•; Osterville Owner: Stuart Boyer Date of Inspection: I;z-6'.Z--d 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 in to protect public health,safety or the environment. 1. System will pass unless Board of Health determines 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. Sy tem will fail unless the Board Health(and Public Water Supplier;'if any)determ'ines'that the + system is functioning in a manner that protects the public health,safety and environment: The system has a septic tank and soifabsorption system(SAS)and the SAS is'within 100 feet oPa='' "'•' ' surl hcc water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS.is within a Zone 1 of a public water supply'..' The system has a septic tank and SAS and the SAS is within 50 feet of a private water sup-1y well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more froril a )aacteria ate water supply well**.Method used to determine distance his system passes if the well water analysis,performed at a DEP certified laboratory, for coliform and volatile organic compounds indicates that the well is free from pollution from that facility and presence of ammonia nitrogen and nitrate nitrogen is equal to.or less that 5 pprn,provided.thataio other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. ther: I - t 3 , Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS , SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORM PART A. . CERTIFICATION(continued) Property Address: _... Owner: _. . . . Date of Inspection: 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 — clogged SAS or cesspool SAS or gg an overloaded or clogged _ Static liqu id level in the distribution box above outlet invert due to cesspool _ Liquid depth in cesspool is less than 6"below invert or available volume is less than'/:day flow _ year NOT due to clogged or obstructed pipe(s).Number Required pumping more than 4 times in the last of times pumped e SAS cesspool or privy is below high ground water elevation. _ of the P Any portion _ 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 privy is within a.Zone l of.a public well. p or p Any portioP n of a cesspool or privy is within 50 feet of a private water supply well. a cesspool or privy is less than 100 feet:but greater than,50;teet tiom.a priyate;watrr ion of P "is rt �s o P f ana Any Psystem asses if the well water y — quality analysis. This y P supply well with no acceptable water q ty performed at a DEP certified faborato'ry;for colifortn.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 an must be attached to this form.) ( es/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 correct the failure. E. arge Systems: g d to 15,000 To be considered a large system the system must serve far,i.ity with a design flow of 10,000 p gpd- You must indicate either"yes"or"no"to each of the following: (The fl Ilowing criteria apply to large systems in addition to the criteria above) ' I 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 siaface drinking water supply _ the system is located in a nitrogen sensitive area(l.nterim Wellhead Protection Area—IWPA)or a mapped i Zone 11 of a public water supply well If u ave answered"yes"to any question in Section E the system is considered a significant threat, answered "yeyos" n Section D above the large system has fzukd.The owncr ar operator of large system considered a d signi cant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.30 .The system owner should contact the appropriate regional office of the Department. W�.. 4 I f Page 5 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM:: :rPART B f . t CHECKLIST Property Address:_ 91 Oldham Rd Osterv' 11 Owner: St fart Boyer _ Date of Inspection: /2—;L—G Check if the following have been done.You must indicate"yes"or"no"as to each of the following- Yes No ,: g„ Pumping information was provided by the owner,occupant,or Board of Health. v Were any of the system components pumped out in the previous two weeks 7 ✓ — Has the system received normal flows in the previous two week period? Have large volumes of water been introduced to the system recently or as part of this inspection 7. Were as built plans of the:system obtained and examined?(If they were not available note as N/A) 1/ Was the facility or dwclling•inspected.for.signs.of sewage:back•up? e/ 'Was the site inspectedfor signs of break out.?:,; -Were all'system components,-excluding the'SAS;located,on site;? • f Were the septic tank,man}ioles uncovered,.opened,.and the interior of the tank inspected for the condition or 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 m ' tenance 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 t Existing information.For example,a plan at the Board of Health. — _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)) - ., . lE ... .. •-fit x •'ll \t..2. ... ..la• ff v �f . .+.. , .. 4 5 . Page 6 of 1 I OFFICIAL,INSPECTION FORM—,NOT.FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL.,SYSTEM INSPECTION FORM SYSTEM INFORMATION Property Address: 91 Oldham Rd Osterville Owner: Stuart Boypr Date of inspection: �— FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x M of bedrooms): Number of current residents:� Does residence have a garbage grutder(yes or no):%Z?� Is laundry on a separate sewage system(yes or no):,1,0 [if yes separate inspection required] Laundry system inspected(yes or no)*0 Seasonal use:(yes or no):�i d Water meter readings,if available(last 2 years usage(gpd)): Sump pump(yes or no):N U Last date of occupancy: . COMM CiAL/INDUSTR.IAL Type of es blishment:; Design no (based on 310 CiviR 15.203): t;pd Basis of d sign flow.(seats/persons/sgft,etc.): Grease tra present(yes or no): Industrial aste holding tank present(yes or no): 'Non-sani waste discharged to the Title 5 system or no):— Water ter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Was system pumped as pi"fthe inspection(yes or no)./-o If yes,volume pumped:_gallons--How was quantity pumped dctctiriined? Reason for pumping: TYP�F SYSTEM �Scptic tank,distribution box,soil absorption system _Single cesspool Overflow cesspool ._Prvy . —Shared system(yes or no)(if yes,attach previous inspection records, if any) _Innovative/Altemative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) —Tight" Attach a copy of the DEP approval _Other(describe): Approximate age of all components,date utstalled(if known)and source of information: 70 ,5�0 `� Were sewage odors detected when arriving at the site(yes or no):A-0 6 Page 7 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS. . , SUBSURFACE SEWAGEDISPO" SAL SYSTEM-INSPECTION FORM -:PART C :4 SYSTEM INFORMATION'(continued) Property Address: 91 Oldham Rd OGterville Owner: S part Boyer Date of Inspectionv4o t-6 BUILDING SE . ER(locate on site plan) Depth below gra : Materials of con ction:_cast iron._40 PVC_other(explain): Distance from p ivate water supply well or suction line: Comments(on ondition of joints;venting,evidence of leakage,ctc.) - SEPTIC TANK: /(locate on site Ian plan) Depth below grade: ► `! Material of construction: ✓oncrete_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.j certificate) , , Dimensions: l Sludge depth: tS`` ;. Distance Gom top of sludge to bottom of outlet tee or baffle: 4 -_ Scum thickness: Distance from top of scum to top of outlet tee or baffle e-1 Distance from bottom of scum to bottom of outlet tee or_baffle° How were dimensions determined:_ (-) 6;� w- -'., I Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels' as related to outlet invert,evidence of.leakage,etc.): /U v lL nIr i s GREASE TRAP:_(locate on site plan) Depth below ade: ..- - -- -- Material of c nstruction:_concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickne s: Distance fro top of scum to top of outlet tee or baffle: Distance fro bottom of scum to bottom of outlet tee or baffle: Date of last umping: Comments( n pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels- as related t outlet invert,evidence of leakage,etc.): 7 t i Page 8 of 11 OFFICI AL INSPECTION FFORM NOT FOR VOLUNTARCTION FORM ASSESSMENTS SUBSURFACE SEWAGEDISPOSAL SYSTEM INSPE PART C SYSTEM INFORMATION{con"timed}'` Property Address: 9�—dham n a ; O G} r., i i Owner: ar Bo er Date of Inspection: TIGHT or HOLDING T K: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: - other explain): Material of construction: concrete metal fiberglass___polyethylene 1 Dimensions: allons Capacity: allons/day Design Flow: Alarm present(yes or no): Alarm level: _ Al in working order(yes or no): Date of last pumping: Comments(condition of larm and float switches,etc.): DISTRIBUTIO.N.BOX:., (if pr 11 esent must be opened)(locate on site plan) Depth of liquid level above outlet invert: 0 evidence of solids carryover,any evidence of Comments(note if box is level and distribution to outlets equal,any leakage into or out of box,etc.): PUnIP C MBER: (locate on site plan) Pumps in w rking order(yes or no): Alarms in rking order(yes or no):. Comments note condition of pump chamber,condition of pumas and appurtenances,etc. : -- 8 Page 9 of 11 OFFICIAL INSPECTION.FORM-NOT FOR VOLUNTARY,ASSESSMENTS. SUBSURFACE SEWAGE.DISPOSAL,SYSTEM JNSPECTION FORM PART C SYSTEM INFO,RMATION;(contutued) , Property Address: 91 Oldham Rd Ost'erville Owner: Stuart Boyer Date of Inspection: i12--D -o^ 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: innovativi/alternative system Type%name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp.soil,.condition of vegetation, etc.): _.... _... .._ . F CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on siie'plan)' ' Number and config ation: Depth—top of liquid o inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool Materials of constructio Indication of groundwat r inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: (locate on site plan) Materials of constructio . Dimensions: Depth of solids: Comments(note conditi n of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS , SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM SYSTEM INFORMATION(continued),s,. Property Address: 91 Oldham Rd nGtPr�ille : •.. .. , Owner: S+-„ari- Boyer 7- Date of Inspection: /7-6 -6 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. 10 I � s Page I 1 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C . ...^ SYSTEM INFORMATION(continued) Property Address: r)jjhaw Rd _OstarviIle Owner: St;l, z:t Boyer Date of Inspection: SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water )feet - Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-if checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 eet of SAS) . Checked with local Board of Health-explain:A0 �% Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the hi h groumd water elevation: 5 6 • Y , t