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0136 OLDHAM ROAD - Health
136 Oldham Road Osterville P A = 120 121 o N .._.:.:'.7��....... Fps:-3�.................. THE COMMOKWEAL'iH OF MASSACHUSETTS BOARD OF HfEALTH �.®.W TJ ......OF.... ...- .IiJ ..P .N 5 A..?._1�................................. Applir�a#ion for MspwiFal lark, Tomitrurtinn Prrnti# Application is hereby made for a Permit to Construct 4-ror Repair ( ) an Individual Sewage Disposal System at: --- - -0.. . ,......X.YQ. ------------------------ ----•-....-•-_Q,t %--•.....`•-....... •-----.................-----------•-•-- Locatior ddress or Lot No. ........ --•- •................: -................... ------•------------ -------- _ M Addres i Installer Address UType of Building Size Lot.._.l ----.'Sq. feet Dwelling—No. of Bedrooms.............................................Expansion Attic ( ) Garbage Grinder ( ) '4 Other—Type of Building -•--_-______- No. of persons.......................... Showers Cafeteria a YP g ------------- P ( ) — ( ) p-' Other fixture _-_ Design Flow......!!�A�.�._-_-_ s- e.1____ralIons per person per day. Total daily W WSeptic Tank—Liquid capacit}/,�� -gallons Length____-____-_-_- Width_............. Diameter__._--__-___--_- Depth................ x Disposal Trench—No................... idth_............__� To al L gth____..............__ Total leaching area....................sq. ft. �.. Dime rs ...___.. }} inlet.................... Total leaching area ft. � Seepage Pit No..... /I� g q. Z Other Distribution box ( ) Dosing tan '-' Percolation Test Results Performed b 1 `......6.,Ae 'd v...... Date_._�_.-_�.l'.�.__:.__.._. aTest Pit No. 1.... ____...minutes per inch Depth of est Pit.................... Depth to ground water--_---_______-__---_--_. Gi, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ------ . . /----- Description of Soil Q--..--�• -- -'_........ '--- ----- _Q f�•A�� < �`a -- � W U Nature 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 TIT1 U 5 of the State Sanitary Code-The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Sigd7"fi-- ../�..--•--------------•-•-----•--•---------•---.-.--- --_-------_------------ Date Application Approved B .-.._-.___ 1�6 .................. Date Application Disapproved for the following reasons:......................V..................................................................................... - ....................................•---...--•----•-------•...------------••-•.........-•.....------•....--------------------••---•-•--••----.._......----•...-••-•---- Date Permit No. ...................................... Issued No.. --• ....._...... Fss ......_........... THE COMMONWEALTH-OF MASSACHUSETTS BOARD OF HEALTH t. Appliration for Ui ipos al Works Toustrn.rtion Vamit Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal System at tee ................ _.... ........... ......................... .......... - - -•---•------• ----.......---- Locatio -Add ress ` or.Lot No. ..... ............. .. 1:. Pl.............................................................. O Addres _...... Installer : ' . Address Type of Building Size Lot___ ! .f>:' ` Sq: feet U Dwelling—No. of Bedrooms........ ...............................Expansion Attic ( ) Garbage Grinder ( ) Other—Type e of Building .. No. of persons............................ Showers p., yp g - ,-- p ( ) — Cafeteria ( ) 04 Other fixtures d W Design Flow----- A ---- 1171gallons per person per day. Total daily flow.............��"'..��.. �..�_..gallons. WSeptic Tank-Liquid capacity ` gallons Length................ Width................ Diameter________-___. - Depth................ x Disposal Trench—No. .............. .... Width.................. Total ] gth.................... Total leaching area----................sq. ft. Diarn�tk*i1A`.9_.__.....4'1 li' below inlet.................... Total leaching area.2121......sq. ft. Seepage Pit No._..+� ....___. Pt Z Other Distribution box ( ) Dosing to aPercolation Test Result ' Performed by `.. :_ "`:.. .!7.t. 0 ' ..... Date... -��_- �....__. Test Pit No. 1.._. ,_._.;.minutes per inch Depth of est Pit.................... Depth to ground water................... Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth t ground water........................ Description of Soil---........................4. .... _ ....? "...0 '�---------- [.pW.4, ---- 4.,�Z f- x V --------------------------......................................-...................................................................................................... W ---------------------------- . --------------------------------------------------------- ...•. ---------------------------------------------•------------------ UNature of Repairs or Alterations—Answer when applicable :..:.............:.................................... ........................ ' -----------------------------................................................................-.............................................. C----------•--------•----..................._.. Agreement The undersigned agrees to install the aforedescribed :Individual Sewage Disposal System in accordance with the provisions of TITLL 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until-a Certificate of Compliance has been issued by the board of health. Sig .'d ............. ------...... r Date �.. ''��/ Application Approved By,..... f- .- 4 l --- ,: Application Disapproved,<f or.,the following reasons:--------------•-------.......................................................................................----....-----•--•----•---------••-----------------------•-----------.Date.......•-••-- •................................................................•---------............-.------.......••-'--------------------------------. ....-------------- ------•---------------••------. Date Permit No................... - --•---- __.._.. Issued.. ... ...........•------ ----•------- ----------- Date j THE COMMONWEALTH OF MASSACHUSETTS! BOARD ' OF HEA TH ............ 6 ... .....OF....:./ + ` ... '. . .,.............................. k rtifiratr of f�oaxt H atta THL�JS TO CCER r FY•„f at,the I}�di idu Sewa is sal S`_stem constructed ( or Repaired ( ) by..... ----•. --• .................- .._ ...--••-------------•-••---....-------••--•----..... at....................................... ...... � has been installed in accordance with the provisions of F off The State Sanitary Code as desc�ib d in the application for Disposal Works Construction Permit,N ..:....................... dated_+y,._../-2-_�40".._..__._.._.. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION ,SATISFACTORY. DATE............. ... Inspector.. :: . ...-_.--3....._.. .__... ... ._.... .fi. ......................... }.._..__.._._._._........._.............. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEA TH � l - No.......L....... OF.... FEa..&') .. Disposal lVarkv T.ono#ritrtion r i� Permission is-hereby granted------ ----- - - .... .... ...... ---- -- to Construct ( or Repair ( n Indivldual Sewage ] isal System atNo...- z.f .• c .' p;a `/ ............................................. --....... 4� - � � Street as shown on the application for Disposal Works Construction r it N .. _.. .___ "Dated. _ w .---....-. .... . ...._... -------•--------- t Board of Health DATE--------- .............. .................. FORM 1255 HOBBS & WARREN. INC., PUBLISHERS'—.. SI�IGt_� �otintL�( - 3 F3t=>eOoA& t`Low = Ito 4. 3 t 33o 4-P.V. " 33ov Inc % 6.t?D. U S+c l o0o saw. �I SPOSAL PIT - u5E I o0o GL�. 1�� /� Ij G X SaX-U/ALL AQEA = tc S.t=. �Kt? MIQ LA A.C� T- lc;o SF 2.S + 3"75 G.P.D. OtS�, I'iOK $oT-rO,fA AOSA= So sr-. SID Sri. x I •o _ So IS-P D. TOTAL -C;)ESI6W = 4SSG4�-- ToTQ PMlZCOLflTIOLJ 0&7-= : CIO 2MIu' o2 ZZ� ism10 Yt•t51T l�q,. . ON� AutiM1, .? WILLIAM c. rV. fora vE tir lY�f Ci:,C�..�/�' ,•� , z �zl T�sT T01- P-4o = �URM �.PvP t000 iuv A d 4�pP& Iw. GAL. it.� :r v't��. - Sul K. f -a3ox �1G�S Sepnc o tNv ( TAMIC I V. GAL.AL. 4 � � LVEAG'H : . U was►aaD i STOW E o�. ' za. _ CE[zTtF1Et7 PUco, pL-.4.V-1 U P20�-iL_� LOCATIO" U`.,TG?UILL,L, �AA, -j Z. t.Jo 11_ScaL.�- ��,CAt_i„ 1 --.di-U �3AT(✓ 3,�, �� do V..►AT(�P 1 CG R T t t=-( THAT T 14 r- PV-bP- PIk� -SuavvQ WS;,`'(-:0" GC�VtPLVG W IT►-i TWE: 51DE t_ NE—:- Awr> SE.~reACV V:c4u10EAAE-.uTS of -rNE "ro va w or- a AW STIR Crl= RCGIS rc=r:�.D 1-�.N� 5u2v`Yo�s T1415 pt-A" IDS LJOT L.&5r--V vat A" OSTev-v%,-LG o MASS. 1WS('CJ.VIC:W i �iUt;�/t_�{ APPL-t GAt- f'T -k�T c v ec, r�, t�cre �•tt►Jt_ Lc�'T' LiWa Dc -wlS � �- S1>,JGI_� �[aMtL`•f - 3 }3t�tZppA/� � � � :.: � `" Udt Lam' F'LAw = Ito v. 3 = 33o G•P-tU. l Ic T�k = 33ov 15c % _ d-95 6.PD. USE- l o0o sAL. j215pc5AL PtT - USE l o0o G&J-, SUMWALL A r A = t5O S.P. Kam' `- M10 u'a ru �►1"r 1 cj0 SF 9 2.5 • S7 7S G.P.D. _ 01ST, 5,y BOTTOM AQEA z CE;O S1=. 0 S 9 =. A I .o SO G.PD. k- 3 TOTA r L -Or = 425 vG�A1�K PMgCDL&TXOLJ tFWM . CILJ 2Mlu' O¢ IX--SS. -F. Z721 WtT1lAN g yy C. JON N Y E yj3 Na tQ9 140. 19331 I TesT Top rwo 'L►oo.o 4- wAA� �e Rae I o0o Iuv .4 d 4'PP6 IW. -Box RGa s � ,o v tu To at K IwV ION. •., GAL. M L�H 9G�3 PIT . W IT*" �} U WAf+J�D STowf !S, CEQTIFtED pLOT' PL /�i<�.1 uo S�Q.�a �CAI_C- 1�-.Q-U, T -wrgn S 8� C G tZ T i!"-t Ti-(AT T t4 l= 1-162 G os-1 W I TiA T►-a S i D E LI►Jl= �--C�T �F•� Ak1c� SC--rVj CV V -QUICEAAE"TS OF T►-aE 9ZEGIS't-t2ED L.AWO 5UZ.Va eUt~e, '('6-11 a C7t_Ah.l 1 IJOT PASC'D OSTev-v% -LG o MASS. tWryf�J,4/tC=IJ i >lJi:�/t��{ i -('►!L- oFrc��T'�, �il1GWLD QPPLI GA.t�.1T k7r u=.cc� ro Dt~rcL mt►J LO-V 1_114a. - DC'UutSqR-l` Tv1?4J (" TOWN OF BARNSTABLE LOCATION 134 01CARIM Q�. SEWAGE # `✓ILLAGE O—Sreryi 16- ASSESSOR'S MAP & LOT 190^ I�j INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY j 5�W LEACHING FACILITY: (type) CV C-(, %30%S (size) NO. OF BEDROOMS 3 BUILDER OR OWNER —:YQ�AQ 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 leachin facility) 1 Feet en � Furnished by�4.5 Snt� . Fdr G i 1 eq�k a IF- 3 y& 3a y ya, 3y o � G 2 I_ TOWN OF XBSTABLE Qt7ATION J O �'`AM" (�0 SEWAGE # 1-/ �O VILLAGE ���i crv� (�� °" ASSESSOR'S MAP'& LOT 'y '- INSTALLER'S NAME&PHONE NO r U GP 1 10.fi ;Ire s ° a8 Saq SEPTIC TANK CAPACITY /$o©-G RL . r LEACHING FACILITY: (type) Cv.Cle c 330 , (sizq� a y._ 60 NO.OF BEDROOMS BUILDER OR OWNER �oY�/l 1\Gail PERMITDATE: I a -�� -c11 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 leac6g facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by arc►n'� �v� le 4O 1 ,, LOCATION SEWAGE PERpIT 00. /36 0 CO/h1^1 �PO A?-,® VILLAGE C� IUSTA LLER'S NAIAE 8 ADDRESS ` ,-10 C�es 5� �,v NPR )IV 53 0UILDED OR OWNER CPo Cr DATE PERMIT ISSUED -3_,? _ Ro DATE COIAPLIA .HCE ISSUED __ _ �� _ _ 2� �? � � �� O� � ��``I'�' 3 �1� r f . �• l-DTy�TOWN OF BARNSTABLE ,;LOCATION 3 �' D Id SEWAGE # VILLAGE ASSESSOR'S MAP& LOT INSTALLER'S NAME&PHONE NO. /- b /0 -n e—S SEPTIC TANK CAPACITY I b w c _ { LEACHING FACILITY: (type) ,�/d' �? (size) G .2 S��e NO.OF BEDROOMS BUILDER OR OWNER �' L►� PERMTTDATE: 3 2-6 ��d COMPLIANCE DATE: t711 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 hi ng f, ility) Feet Furnished by ` )�-�.S . ��nf�. �/f/f� 37 d � • ,.°ITS � ' r r,-1w s cell TOv�W/N O6t4gW7jAftW �-_lOCATIONR®TS /,90 -AR I 30,6y!5 f.4)UtP SEWAGE # �� / 42 VILLAGE QS 9 P Q j I I ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. o)d0N ujn _( !SEPTIC TANK CAPACITY 1000 A. '`ILEACHING FACILITY:(t ) - � W i 1 9Pe a (size) /� �( �6 NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER(Py�IiC BUILDER OR OWNER �QdYj DATE PERMIT ISSUED: �F `71, DATE COMPLIANCE ISSUED: `" ' VARIANCE GRANTED: Yes No g . j `fM 55)` V'+ 2 1 �/ I a\ COMMONWEALTH OF MASSACHUSETTS � EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS . DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION J2� MAP Property Address: .136 Oldham Road 2 Osterville, MA 02655 PARCEL Owner's Name: John Reen LOT Owner's Address: Date of Inspection: November 24, 2003 DECEIVED 6 Name of Inspector: (Please Print) James M. Ford Company Name: James M. Fora DEC 2003 Mailing Address: P.O. Box 49 TABLE Osterville,MA 02655-0049 TOWN OF BARN F HEALTH DES T Telephone Number: (508) 862-9400 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based,on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ✓ Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority ' Fails Inspector's Signature: Date: November 30, 2003 The system inspector shall subm copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 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 ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 t Page 2 of 11 y OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 136 Oldham Road Osterville, MA Owner: John Reen Date of Inspection: November 24, 2003 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: ✓ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health, will pass. Answer yes,no or not determined(Y,N,ND) in the for the following statements. If"not determined", please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not),is.structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: l The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: M 2 l Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 136 Oldham Road Osterville, MA Owner: John Reen Date of Inspection: November 24; 2003 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. 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. System.will fail unless the Board of Health(and Public Water Supplier, if any)determines that the system is functioning in a manner that protects the public health,safety and environment: The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 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 supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This.system passes if the well water analysis,performed at a DEP certified laboratory, for coliform + bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. - 3. Other: 3 Page 4 of 1 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 136 Oldham Road Osterville, W Owner: John Reen Date of Inspection: November 24, 2003 D. System Failure Criteria applicable to all systems: You must indicate either`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 ✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ✓ Liquid depth in cesspool is less than 6" below invert or available volume is less than '/z day flow ✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped ✓ Any portion of the SAS,cesspool or privy is below high ground water elevation. ✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ✓ Any portion of a cesspool or privy is within a Zone 1 of a public well. ✓ 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 than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] No (Yes/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. Large System: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) J Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area- IWPA)or a mapped Zone 11 of a public water supply well If you have answered`yes"to any question in Section E the system is considered a significant threat,or answered "y?s" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 4 f Page 5 of 1 I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 136 Oldham Road Osterville, MA Owner: John Reen Date of Inspection: November 24, 2003 Check if the following have been done: You must indicate"yes"or"no"as to each of the following: Yes No ✓ Pumping information was provided by the owner, occupant,or Board of Health ✓ Were any of the system components pumped out in the previous two weeks? ✓ Has the system received normal flows in the previous two week period? ✓ Have large volumes of water been introduced to the system recently or as part of this inspection ? ✓ Were as built plans of the system obtained and examined ?(If they were not available note as N/A) ✓ Was the facility or dwelling inspected for signs of sewage back up? ✓ Was the site inspected for signs of break out? ✓ Were all system components, excluding the SAS, located on site? ✓ Were the septic tank manholes uncovered, opened,and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid,depth of sludge and depth of scum ? ✓ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes No ✓ Existing information. For example,a plan at the Board of Health. ✓ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)]. 5 f Page 6 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 136 Oldham Road Osterville, M4 Owner: John Reen Date of Inspection: November 24, 2003 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms.(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 0 Does residence have a garbage grinder(yes or no): Yes Is laundry on a separate sewage system (yes or no): No [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings, if available(last 2 years usage(gpd)): Unavailable Sump Pump(yes or no): No Last date of occupancy: Unknown COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sqft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no) Non-sanitary waste discharged to the Title 5 system (yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Unavailable Was system pumped as part of the inspection (yes or no): If yes, volume pumped: _gallons-- How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM ✓ Septic tank, distribution box, soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight Tank Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: . Jan. 6198-per as built card Were sewage odors detected when arriving at the site(yes or no): No 6 6 Page 7 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 136 Oldham Road Osterville, MA Owner: John Reen Date of Inspection: November 24, 2003 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron _40 PVC other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage, etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 10" Material of construction: ✓ concrete _metal _fiberglass _polyethylene _other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 1500 gal. Sludge depth: 1" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: 1" Distance from top of scum to top of outlet tee or baffle: 8" Distance from bottom of scum to bottom of outlet tee or baffle: 10" How were dimensions determined: Measuring stick Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): .Tees were present. The liquid level was even with the outlet invert. There did not appear to be any signs of leakage GREASE TRAP: None (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(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): I 7 f Page 8 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 136 Oldham Road Osterville, MA Owner: John Reen Date of Inspection: November 24, 2003 TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete _metal fiberglass _polyethylene _other(explain): Dimensions: Capacity: eallons Design Flow: gallons/day Alarm present(yes or no): Alarm level:, Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Even Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover,any evidence of leakage into or out of box,etc.): The D-box was level. No solids were present. The interior was clean. There did not appear to be any signs of failure or backup from the leach field. PUMP CHAMBER: None (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no) Comments(note condition of pump chamber,condition of pumps and appurtenances, etc.): r 8 l Page 9 of I I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 136 Oldham Road Osterville, MA Owner: John Reen Date of Inspection: November 24, 2003 t SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: ✓ leaching chambers,number: Cultec 330s-27'x 10'(per as built card) leaching galleries, number: leaching trenches, number, length: leaching fields,number,dimensions: overflow cesspool,number: Innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding,damp soil,condition of vegetation, etc.): There did not appear to be any signs of failure from the leach field. The bottom to grade was 4 0' CESSPOOLS: None (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth -top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.): PRIVY: None (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 9 f Page 10 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 136 Oldham Road Osterville, MA Owner: John Reen Date of Inspection: November 24, 2003 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. i ►oo � Q y yl a.3 3 y� -3 y yc�. 3 y { 10 I Page 1 I of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 136 Oldham Road Osterville, MA Owner: John Reen Date of Inspection: November 24, 2003 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 20 +1- feet Please indicate (check)all methods used to determine the high groundwater elevation: Obtained from system design plans on record - If checked, date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) ✓ Checked with local Board of Health-explain: topographic and water contours maps Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Using the Barnstable topographic map and the Cape Cod Commission water contours map the maps were showing approximately 20'+/-to ground water at this site. rl This report has been prepared and the system inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed, written or implied, relating to,the system, the inspection and/or this report. 11 3 r7,-., No. 7 2 -) Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01ppYicatiou for Migozar *pgtem Com5truction Vermtt Application for a Permit to Construct( )Repair(!/Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. /Oh A✓h IV Owner's Name,Address and Tel.No. Os;erg, /l C. Assessor's Map/Parcel -aOAR Installer's Name,Address,and Tel.No. L(�g—SC,LAC) Designer's Name,Address and Tel.No. Cie zoe,,X� 01?1"j o2i<_ OST- tat Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan,Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Altera t* s_(_Answer when a . icable) UOC2.Q.r— 1.50 O 64 T,r3-C;: l e C 330 S7` Si�*y1 e •- �' ��ve-11 17X 3/6�•S?ci►e Date last inspected: �vCf{e- � 30,✓���"'�t 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 Certifi- cate of Compliance has been iss d by this oardWoeah. Signed Date PGA°,),2, /i Se. Application Approved by Date Application Disapproved for the following reasons 'Permit No. T 7" 7 2-7 Date Issued 1 Z—P Z—f 7 .--------------------- fit 1 No. DID ,~ 72 }r Fee Entered in computer: l THE COMMONWEALTH OF MASSACHUSETTS Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01pprication for 13i!6pozal *p.5tem Construction Permit Application for a Permit to Construct( )Repair(!/Upgrade( )Abandon( ) ❑Complete System El Individual Components Location Address or Lot No. 1.36 Q loh,9 n1 Owner's Name,Address and Tel.No. Assessor's Map/Parcel Q // Installer's Name,Address,and Tel.No.f t_� —.S (�(.j(� Designer's Name,Address and Tel.No. GO Zb0 rC& A,17v3 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 gallons per day.�Calculated daily flow gallons. Plan Date _ Number of sheets . ^' Revision Date Title Size of Septic Tank ( a Type of S.A.S. Description of Soil Nature of Repairs or Alterations Answer when ap 'cable) Vr1aAD r-— /So G col 7Q,, J.30 L4rifj I r 57pr1 C ISO �7 Ga .TGj '�� S1U.7� 3 c� Date last inspected: C 3301 3 aV4'�°' )" Agrement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions df Title`5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has-been issued by this o=oh.Sined ,� g � *� � � Date Application Approved by } Date a - Application Disapproved for the following reasons 1 _y 1 y,r ..- Permit No. T 7 7 7-7Date Issued ---------------------------------------- THE COMMONWEALTH F MA SSACHUSETTS ASSACHUSETTS BARNSTABLE, MASSACHUSETTS (Certificate of Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired (P')-Upgraded( ) Abandoned( )by at 1 �(c� n k VA YVA 2?n pS'�e r., has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated Installer Designer C i The issuance of this permit shall not be construed as a guarantee that the system will function as designed. Date Inspector .� t No. f -------------------------- �� Fee ) THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Mwi5po$al *p$tem Construction Permit Permission is hereby granted to Construct( )Repair(U�pgrade( )Abandon( ) System located at 13[5 4/O/7/Iis t and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Construction must be completed within three years of the date of this permit. Date: /�� Approved by 2 ` - I TOWN OFXSTABLE LOCATION O �o V1 A 1'�t�0 SEWAGE # :::' =CAGE OS"T"c r v, (�C ASSESSOR'S MAP &LOT NSTALLER'S NAME&PHONE NO,r u G e_ 1 1 cc�V k s Cr :'::SEPTIC TANK CAPACITY /500 GRI, LEACHING FACU rrY: (type) IZec 3.305' (size), OF BEDROOMS BUILDER OR OWNER Ix�een f'AMITDATE: I a. -11 •`I1 COMPLIANCE DATE: :;'Separation Distance Between the: :`:Iviajumum Adjusted Groundwater Table and Bottom of Leaching Facility Feet ' r'vate Water Supply Well and Leaching Facility (If any wells exist >:':,gn.site or within 200 feet of leaching facility) Feet :'Irdge:of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet :.Fwrc-t hed by - �tie 4S I� i 10/9/97 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT ENGINEERED PLANS) hereby certify that the application for disposal works construction permit signed by me dated /�c°�02 l q of? ,concerning the property located at Q�ra�Am �� - 4s e���/E meets all of the �, 6 following criteria: There are no wetlands located within 100 feet of the proposed leaching facility • There are no private wells within 150 feet of the proposed septic system • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. • If the proposed leaching facility will be located within 250 feet of any wetlands,the bottom of the proposed leaching facility will nQt be located less than fourteen(14)feet above the maximum adjusted Z' 91y r groundwater table elevation. /7 Please complete the following: A)Top of Ground Elevation(according to the Engineering Division G.I.S.map) ��i� B)Observed Groundwater Table Elevation(according to Health Division well map) 4T SIGNED: DATE: O79 LICENSE SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER [Attach a sketch plan of the proposed system.Also If the licensed Installer posesses a certified plot plan, this plan should be submitted]. q:health folder:cert r 3- c,/7cc e S c/aejeo lL ew-t,� b7 I � Sov Gil /i.-'l0lla, P r . r A TROY WILLIAMSf # A 1 �� SEPTIC INSPECTIONSr 1 6��® a r Certified by MA Department of Environmental Protection /4.; '? j608) 760-1819 40 Old Bass River Road f4.. South Dennis,MA 02660 �'' ��� _,, " +� ' , v� Commonwealth of Massachusetts P y Executive Office of Environmental Affairs Department of Environmental Protection William F.Wald Trudy Cox* Paul Calluccl David B.Struhs CormrNdor»r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A _ CERTIFICATION Property Address: �,3 6 K d, O S�-v- ✓J t x Address of Owner. `f O 1, e` �^ Date of Inspection: 7Ict y6 (If different) Name of Inspector.— 3 3 C GrcS�Hv� rTj�� �vc Company Name,Address and Telephone Number. �r y/ /l/1... G 3S CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,acm-te and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: _Zpasses _ Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signature �sCJ Data 7 /g lCf6 The System Inspector shall submit a copy of this inspection report to the Approving Authority within 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,the inspector and the system owner shall submit the report to the appropriate regional office 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. INSPECTION SUMMARY: Check A1,B,C,or D: A] 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. B] SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system,upon completion of the replacement or repair,passes inspection. Indicate yes,no,or not determined(Y, N,or ND). Describe basis of determination in all instances. If"not determined",explain wbyy not) The septic tank is metal,cracked,structurally unsound,shows substantial infiltration or ezfihration,.or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a lonforming septic tank as approved by the Board of Health. (revised 11/03/95) 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A / CERTIFICATION(oontinued) Property Address: 3 G 0/� u•••� Owner. Date of Inspection: B]SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken 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): broken pipe(s)are 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 Cl FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: /1(4 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 WILL 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: 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 FUNCTIONING 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 within 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 pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. 3) OTHER (revised 11/03/95) 2 SUBSURFA CE SEWAG E DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: /3 t; Q Owner. D Date of Inspection: I\«'L" D] SYSTEM FAILS: I have determined that the system violates one or more of the folio this determination is identified below. The Board of Health should be contactedwing failure todeterrmi as nwh m�be�nec necessary greet th The basis e faihue. . — Backup of sewage into facility or system component due to an 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 dogged SAS or cesspool. — Static liquid level in the distribution box above outlet invert due to an overloaded or cloggedSAS or cesspool. pool — Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow. — Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped — 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 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 analysed to be acceptable, attach copy of well water analysis for eoliform bacteria, volatile organic compounds,ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: Al The following criteria apply to large system in addition to the criteria above: The system serves a facility with a design flow of 10,000 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 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 lI of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 11/03/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Addresx Owner. Q Date of Inspection: 9e Check if the following have been done: YPumping information was requested of the owner, occupant, and 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 inspection. �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. ✓The system does not receive non-sanitary or industrial waste flow _I'he site was inspected for signs of breakout. All system components,excluding the Soil Absorption System, have been located on the site. ZThe septic tank manholes were uncovered,opened, and the interior of the septic tank was inspected for condition of taffies or tees,material of construction,dimensions, depth of liquid, depth of sludge,depth of scum. The size and location of the Soil Absorption System on the site has been determined based on existing information or /approximated by non-intrusive methods. The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub- Surface Disposal System. (revised 11/03/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: Owner. t e, Date of Inspection: / � q RESIDENTIAL. FLOW CONDITIONS Design flow:o Number of bedrooms: Number of current residents: Garbage grinder(yes or no):�F S �, + , c,. •+s a+ Laundry connected to system(yes or no):_1C- S Seasonal use(yes or no):__?CS Water meter readings, if available: S _ d Last date of occupancy: S c.,.� / rnl G LKc COMMERCIAL/INDUSTRIAL. A//A Type of establishment: Design flow:_____gallons/day Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)— Non-sanitary waste discharged to the Title 5 system: (yea or no) Water meter readings, if available: Last date of occupancy: OTHER:(Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: / I /Y�- ��H'1,Les• !n�J /�c c_.d.i�/l S - `'a ( C.� L L �-System pumped as/part of inspection. (yes or no)_,i,/o . If yes,volume pumped: gallons Reason for pumping. TYPE OF SYSTEM YSeptic tanWdwmbution box/soil absorption system Single Cesspool Overflow cesspool Privy Shared system(yes or no) (if yes, attach previous inspection records, if any) Other(explain) APPROXIMATE AGE of all coponents, date installed(if known)and source of information: � �/�.c to �/ /a 3 /8 d 12�r a S- b� / Sewage odors detected when arriving at the site: (yes or no) I/d (revised 11/03/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 134, Owner. 9< Date of Inspection: SEPTIC TANK_✓ (locate on site plan) Depth below grade: Material of construction:Zwncrete_metal_FRP—other(explain) ` Dimensions: S Sludge depth:_ Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: 0 /F Distance from top of scum to top of outlet tee or baffle: IV Q S C_ cam., Distance from bottom of scum to bottom of outlet tee or baffle: NU S C-vs., . Comments: (recommendation for pumping,condition of inlet and outlet or baffles,depth of liquid level in relation to outlet invert,structural integrity, evidence of leakage,etc.) �— &J a r-e ; h r h v o Al e V O !� Nn o+ O�[n c� p 4t- c 7"_ GREASE TRAP:-6f/,q (locate on site plan) Depth below grade: Material of construction:_concrete_metal_FRP—other(explain) Dimensions: Scum thickness: Distano from top of scum to top 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 baffles,depth of liquid level in relation to outlet invert,structural integrity, evidence of leakage, etc.) (revised 11/03/95) 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1,3 Id wH, Owner. R«i-I Date of Inspection: 7/9 1194 y6 TIGHT OR HOLDING TANK: (kxate on site plan) Depth below grade: Material of construction:_concrete_metal_FRP—other(explain) Dimensions: Capacity:- mllons Design flow: gallons/day Alarm level: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert: y Comments: (notes if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box,etc.) �'-�3oir W a S TD J K 1 G cJ t ' U /.. u1 / o 1.— Ct G r PUMP CHAMBER_,�k/�j9 (locate on site plan) Pumps in working order.(yes or no) Comments: (note condition of pump chamber, condition of pumps and appurtenances,etc,) (revised 11/03/95) 7 i ' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(oontinued) Property Address: Owner. Date of Inspection: G (" SOIL ABSORPTION SYSTEM (Sm),_Z (locate an site plan'if posnble;excavation not required,but may be approximated by non-intrusive methods) If not determined to be present,explain: Type: leaching pits, number: O r.t.. X 6 / t �/T wZ 'S H t . leeching chambers,number._ leaching galleries, number: leaching trenches, number,length: leaching fields, number,dimensions: overflow cesspool, number: Commes: (note condition of soil, signs of hydraulic failure, level of ponding, condition of ve Bonetc.) !� ✓GI.I c. flj� , o r 1p Z CESSPOOLS:L/,9 (locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer. Depth of scum layer. Dimensions of cesspool: Materials of constriction: Indication of groundwater: inflow(cesspool must be pumped as part of inspection) Comments: (note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY:—L/114 (locate on site plan) Materials of construction: Depth of solids: Dimensions: Comments: (note Condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.) (revised 11/03/95) 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner. Da Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: Indude ties to at least two permanent references landmarks or benchmarks locate all wells within 100' a3 ' 3� �(o' TAN►'y 4 I � i 3 Q_6UX DEPTH TO GROUNDWATER Depth to groundwater, feev adjusted high groundwater level method of determination or approximation: A ' 1, G t_ Q / 9