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HomeMy WebLinkAbout0236 OLDHAM ROAD - Health 936 Oldham. Road Osterville P A 145. 013 w �. 1 • 0 No...................• e`+i�s.. ................._ THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH Q-LU.AU.........-.OF......( ! 'I• '� 18. .. ................... Apli iraa#ion for DisplaiiFal Works Tonstrnrtinn Famit Application is hereby made for a Permit to Construct ) or Repair ( ) an Individual Sewage Disposal System a .�. _...Q--.Cc .&q...I.........0 ? v� _,/.M '------- ............. - .Jv*Mtion-Address t No. 0.�tg pa e " . �1 -' Own � dress .... ' j....--•------------- --......._.....Installer r Address /�2© Type of Building - Size Lot..................... .....Sq. feet ,., Dwelling—No. of Bedrooms.. .....................................Expansion Attic Garbage Grinder Other—Type T e of Building .............. No. of persons........ Showers — Cafeteria 4 a YP g .............. P (� ( p Q' Other fixtures .......................................................... Design Flow.....__. ... 15..................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 at ( ) �� �,s aPercolation Test Results Performed by.... ...... ..... _..U /..��t1. Date.............:. _(„_! Test Pit No. 1<. ,6minutes per inch Depth of Test Pit.................... Depth to ground water.......f_.............. f=, Test Pit No. 2.<-2.,.0 minutes per inch Depth of Test Pit.................... Depth to ground water........................ .......................... t O D�escription�f Soils "2f v - --------�Q----- !Pr.I .S.�X✓�6-----aQ---�"�-Z�--��,sl���,1.f�------------------------------------------------------------------------------ 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 iITIU 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has .een 's ued by theayoaMh ,S ne -• •. ........ • ------- .... - ��✓ Date Application Approved By..... --•_. :_. ZZr1,Aj ------------------------------ --.�� Date Date Application Disapproved for the following reasons------------------------•--------------------------------------•--------------------------------------.....------ ....•--...•---•-••-------------------•-----•-•-•-----•-••-...............----------------..._......---•---•-•--•-----------•---•--•------•-•-------•••••---••-•••-•-••---•-----•----•-•-----••---------- Date Permit No.................................... -------------------- Issued_..... --f -------- -- ............................. Date THE COMMONWEALTH OR .MASSAC: IUSETTS , ..-�-- BOARD OF H EA LT .- .rV...........OF...... i ." ............. ..................... ......... .... yl. ApplirFation for Disposal Works Tonstrurtiun Vrrmit Application is hereby made/for a Permit to Construct ,�) or Repair ( ) an Individual Sewage'Disposal System at: �. 1�• tion-Address r 1 ....--......vS '...1�. .ra " `. .. ....J./..--•---- / il¢. / dress 'f. - i #- Installer "Address � / Type of Building Size Lot........:.::...............Sq. f t Dwelling—No. of Bedrooms............................................Expansion,.�lttic Garbage Grinder Other—Type T e of Building .... No. of persons ........................ Showers Ga YP g •--------------••------- P (2� — Cafeteria ( :� OtheNur + ------------------------------------------------•••••............-••-•-•. <3 W Design Flow.._....3 . �!..................gallons per person per day. Total daily flow...... ...................................gallons. WSeptic Tank—'Liquid capacity............gallons Length................ Width..................Diameter................I Depth................. x Disposal Trench—No..................... Width... ............. Total Length..................... Total leaching area...................:sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area................s . ft. Z Other Distribution box ( ) Dosing n - ' , .* a Percolation Test Result Performed by.... .. .............. ... ......... Date.. ._..............•. ��qq � f ... Test Pit No. 1.'�,. Llliinutes per inch Depth of Test Pit.................... Depth to ground water........................ fs, Test Pit No. 2.... aOriinutes per inch Depth of Test Pit.................... Depth to ground water.............._.......... .......................... SowZ . ' Q . p ,/c-���( ..w. � .��.,."'.. .'.. -'•°--•••'O•-•J-T• , `'+cf- •;--- rx / �. ._ � . .. . .. ...... .............................................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 TI'IE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compli0has ued by the, Tard ie. 2Date Application Approved By•...rz'...... .. L � .. � 17•••-... - Date Application Disapproved for the following reasons:........................ --•-•-.............•...----.......-•--------------........--•-•-.................----- L ............................................................... ................................................---..........----------•-•-•------•----.._....-•------------`..--Date.......------- PermitNo......................................................... Issued-...................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD F HEALTH Ile .... r /® , ` s/........................ O F......... ... ..........-^... .................... ................. Trr#ifirtttr of TompliFanrr TH IS TO CE IFY, hat the Individual Sewage Disposal System constructed (.A or Repaired ( ) by......... /a. .. .... .... ................................. r / Installer p at.....lof... ._. !f._-. ....... ....... *-'-- ' ~ ��f...L.'if has been installed in accordance with the provisions of r of The State Sanitary Code as described in the application for Disposal Works Construction'Permit N .._. I..11 `--------------- dated_.-.Q�`.'.; a THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. F DATE............. .. Inspector----- ----.--•-- .r....F.� ...................... : ............................................ THE COMMONWEALTH OF MASSACHUSETTS BOARD HEALTH R, r �t ,�Q ,,,re ,�/ ........:...'7r,i'/ .............OF...... ...................................... n1 .. ..w+....... v No..............Z. . FEE..... .......... Disposal Works ,n nrtion Prrmit Permission is hereby granted..--- ..... ... . ...... ----------------------•-•-----........---........---........................ to Construct it ) ndi ual S -Di o al s ... ---.•-------•-------------------------...... Street F as shown on the application for Disposal Works Construction Pq=itNo . a.... Dated.......................................... .................... / Board of Health DATE..................................cl.L..BJ...... FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS TOWN O BARNSTABLE LOCATION ')Co � ,n SEWAGE # '—L4 U D VILLAGE '' 1 1IYt'_ ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. t4 SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUILDER OR OWNER Lo � PERMTTDATE: �6 9L!5 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,feA!,t of leaching facility) Feet v Furnished by �, ... _.. .j '.;' y � n ���-cam. .�.� _.� � o � `� _ - � 3� 6 a' �4f �? .��� . - , "'.! � w u L 0 &-A T ON SEWAGE PERMIT NO• VILLAGE IM.STA LLER S NAME i >> ADDRESS ® U I L D E R R 0 NER ; DATE PERMIT ISSUED DATE COMPLIANCE ISSUED t � . o 141 ` t 4 F Ell ^r y� LLi kK a' 3y�� y.7.;J v �h il{ ;+Hr .•� •,�.c q,t M '� T,`-,r,L"y !!d lY. �4. 'e, y 1 _ .. I ,�}. 11 1•. ''� 1 'If Y�ry I �"fyY '�S � �i�t+ { i�, t . ' y a1 s v+ 'S 3,` t o�'t��11'�`Ai'� • 07 � ��\ +rtgi .,�4r� U � � 1` tc• %_ „�,QYYgt ��((,,r{J!', �;a4t� tY '�� �at, �+��p�ta�i� .t ,CrJ � 8� SQ , �, .� •r+ q�,':J3* ,1 y� ,,yy � �,`� ti,y„ •� � ��� ��M1t� � ry�0.1�,�•t K1�t'JSb •CN tj r e l ;tr is !ly7'l� �b}l'�6 r,r� •. '�iQGH//✓�j• F/ELF -a _ t,' y.y '�'�? �'7' � ,+��"t�+i5 1 �,.r, 1 +�Y�L yp�r 'fP..JJ�l�n�' 2oI r / � ✓ "'',.J,.../,����. ��!FT,r+1 r}?�4i,1vo ry'"}�, ,•' i,�..�P.� � ,1'Fi I\ r •�, —' I¢'� 4 - r — -- — — .9 rf r s A 'fF'.�4+ riff�'H_.,+ -(6 1f '9'' t`:.,\ .P'�w•y�i 'F h '0 rdr— �, j xPAArS q" J-A "� Z4' L � " ,+ .�� y �gQti'-:�a � �• SEATI� r , K,� 23.'.. �J's t,•.00�/'T�1��s���� +� �v nt ,�}! r,l/'•Q r�,��y- TRN/r. `1,� '• t5 'Yr {!ktt" y� i • N � Ul `• 3� �,��,d,.� '�'.'q��;�«�i few v I ��•v'Tii! �t. M c }jt� P"'+3y1h4ti ISS, 0 v V _/` i ✓ s- 1U 26 {I/-I �2162p fit . . `. 14, X! 1f. tQ�. �AOT _ ELEVATION O„0 CERTIFI,ED PL;`'aT r iliQNf Pf ,� � ,�4 t-ON tyOUP ..-_ O {—� (l7 3' �!L��."i•� Di ,I/'�S j ti�Y� 1. AF1P1iSF( D=��SPOT" ELEVATION �0 0� _ l a F,aP1>;SH WTOUR --- - O - - D57- �✓ ;r' �r, p s1� '4 I I�C�. 4i ,•1' + t1 1 at bVEJ �'BOARD OF HEALTH �F.y�� JOAABS TO-11 S:, U `+' AGENT SCALE 1 YL • I A�f''ENGINEERlAIG�Ca,ING� DST; ���v R.TZ nr _ CLIENT __ - I CERTII`Ym THAT lit' , R �'®QED ' �• GI$1'tc�1aE 62EGIST•EREQ JOB IdO. �V9� ®UIL'D.ING ',Sh90WNM' rT ��p LAt� s °' AC11�Yt ' ' I LAND CONFORMS ' TO THE;' ZQBJ4_lV,G, a,1�lS 1 l �'t EP ,` SURVEYq OR. BY �. i, OF ®ARNST9:LE A 712.,IIA,1N $T CH. GYKI P_ A MOB Si YANNIS MASS 2 .;H . SHEET-L OF ATE' f41EY�'ift „:. 1 IV.0.T W" A 't-1Z 7- n V,=, 'o, R AVa. .1 A CLEAN -'rAVP .4.1 ST IROAI PIPE / 0 0 GA 4. Al/Al R/7CH • F -- SEPTIC 7"1 C 7'A NX BOXv LEACHING FIELD 6 770N) i.F SEC7'10)V Otc- CoROUND WATEff-TA,6LE SEWAG&E DISPOSAL SYSIrEM I-EACHINO A 3FT. 6 FT 6';C. SCALE 0/^fA-Ar'5/0/V 45- FT. C, 20 I-A YER 4"APOU494E S014 TlEsr . 6,011- LOG0 31B PERFORATED -7 SOIL TEST Af SOIL TE57#2 W1q5W_=,9.37.0,V4r' pl/c PIPE DATEOFSOIL TEST 2-� A-V -f-Lev, 7. RESULTS W1 ZMESSED BY /Z FR 0 - -2- CLAN;l 4-0 A—I -ETcol_A7-1oAl R47-- A 2 fqlq-IIAICH -7 ' C 0 A-f?-S C-7 T DESION CRITERIA -7 4"oo E Tt �7 No NUMBER OP- MDMOOMS, PERPRATEO: 'AVA5RArA*-7761VE - OD J7AN-&S 0A/Z s&7 OffCENTZR` . ESTiMA7RD AL.OW . GAL.10A Y' . AfflEeA 43 2SQ. p,7. T v C SECT/ON X—X RA:5ZRVN . Aq,A SCA 4.,ff OaROUND kVA7,-- N L-lVCO41,VrCWf,0 GAZOVArP WATER'AFR AT C-,L e V • �j ,UF R4 /)VVER77 A7701V5. ' 7 _NX r tj ]ROBERM V, 4?7t W� zDwa P. ft FT ZT. 4Er 62.0 Ile V gy laWn ON 4.0 ON A'Ll tp 4�,N.P. n 5, _A v� W v COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTALAF FAIRS o . DEPARTMENT.OF ENVIRONMENTAL PROTECTION V 'tH gY0 .ra.. TITLE S OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY:ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION I � t Property Address: .4 �qN Owner's Name: Owner's Address: Tb 1 Z C» tiF�Fa Date of Inspectio q�riygRNST QF�Tge�� Name of Inspec (plea a print) be! I' /00 Company Name. _ MAP Mailing-Address:, a G paCA�� PARCEL � �_�_� .Telephone Number:_ �, APT"- -- — I 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 o ,site sewage disposal systems. I.,am a DEP approved system inspector pursuant to asses 15.340 of Title 5(310 CMR 15.000). The system: X P Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fail Inspector's Signature: Date: a- The system inspector shall submit a 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 Commenis-&p ""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 I M r S � Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued]'. , Property Address: JAI Owner:`�� iZ-1 t4i,40,41012A! . Date of Inspection. Inspection80mmary: Check A,B,C,D or E/ALWAYS complete all of Section D A. n S stem Passes: " I have not found any information which indicates that any ofthe 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 syste_,M upon completion of the replacement or repair;as approved by the Board of Health, will pass. f V.� 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: .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 H P ( Health): ) broken pipe(s)are replaced obstruction is removed ND explain: 2 f Page 3 of 11 OFFICIAL INSPECTION FORM-.NOT FOR VOLUNTARY ASSESSMENTS . .SUBSURFACE.SEWAGE DISPOSAL SYSTEM'INSPE.CTION'FORM PART A - CER:TIFICATION(continued) Property Address: Owner:. Date of Inspection: 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. I The system has a septic tank and SAS and the SAS is within a Zone I of a public.w.ater 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 I00_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 S � Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Add ress:0av Owner:GUlv Date of Inspection: D. System:Fail ure 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 Llclogged 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%day flow Required.pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number / of times pumped _ i1 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 — ,—f water supply. I/ ..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. V 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.] 1 (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 Systems: To be considered a large system the system must serve a.facility with a design flow of.10,000 gpdl,tb 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) 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 II of a public water supply well If you have answered"yes"to any questibn in Section E the system is considered a significant threat, or answered "yes"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 Page 5 of 11 OFFICIAL ]INSPECTION FORM - NOT.FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM .PART B r CHECKLIST Property Address: �C Owner: Date.'of Inspection:_ �Q® Check if the following have been done. You must indicate"yes"or"no"as to each of the following:. Yes No tG _ Pumping.information.was provided by the owner, occupant,or Board of Health t/ 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-?"- V"' _ Was the site inspected for signs;of break out? ' Were all system components,excluding the SAS,`locafed on"site?` Were the septic tank manholes uncovered,opened;and the interior of the tank insperted'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. V 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)] ' .. 'j it .1 F, �.�/.f � v .� .( • 5 ° Page 6 of l 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY,ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 3 Date of Inspection: .f'�P/XI -ooa V' FLOW CONDITIONS RESIDENTIAL Number,of bedrooms(design):: . Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 11.0 gpd x#of bedrooms): C8 Number of current residents: - Does residence have a garbage grinder(yes or no�.-_4 Is laundry on a separate sewage system(yes or no): .[if yes separate inspection required] Laundry system inspected(yes.or no): Seasonal use: (yes or n4 '"" . 7��� Water meter readings, if available(last 2 years usage(gpd)):® d®� ©I"�- Sump pump(yes or no)- y Last date of occupancy: COMMERCIA;LANDUSTRI L Type of establishment: . Design flow(based on 310 CMR 15.203): gpd Basis of design.:flow(seats/persons/sgft,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 n Source of information: (9 Was system pumped as part of the iiispection(yes or no): If yes, volume-pumped: gallons=-How was quantity pumped determined? Reason for pumping:. TYPE OF SYSTEM ptictank,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 copyof the DEP approval `f —.Other(describe): A roxim " .a of 1 components, date installed if known)and urce of information: flki Were sewage odors detected when arriving at the site(yes or n 6 Page 7 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS —. SUBSURFACE°SEWAGE DISPOSAL SYSTEM INSPECTION FORM• ► ' .PART:C SYSTEM.INFORMATION(continued) Property Address: ( y Owner: Date of Inspection: C--)00C9 BUILDING SEWER(locate on site piano 1/ J 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:zlocate on site plan) Depth below grade: Material of construction: �oncrete_metal._fiberglass polyethyleiie other(explain). ` If tank is metal list age:— Is age confirmed by a,Certificate of Compliance(yes.or no): (attach;a copy of certificate) y t ill '. Dimensions: �=S. � V Sludge depth:. C`-2 I Distance from top of sludge to bottom of outlet tee.or,baffle: 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: How were dimensions determine4I ,6j� � �� // Comments(on.pumping recomme ations, in et and outlet tee or baffle condition,structural integrity,liquid levels related to outlet invert:, e idence of leak e, etc.): a v GREASE TRAP lbcate 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 cf'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.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART. C SYSTEM INFORMATION(continued) Property Address: Owner [ IL Date of Inspection: 6,dO01P TIGHT or HOLDING TANIC (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: gallons 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:_Z(if present must be opened)(locate on site plan) 4 Depth of liquid level above outlet invert: Comments(note if box is level and distribution.to outlets equal, any evidence of solids carryover, any evidence of J PUMP CHAMIBE8/1 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.): 8 Page 9 of 11 OFFICIAL ]INSPECTION FORM—NOT FOR VOLUN'P.ARY ASSESS MENTS SUBSURFACE SEWAGE'DISPOSAL SYSTEM INSPECTIONrFORM PART C SYSTEM INFORMATION(continued) Property Address: Owners (itf, Date of Inspection: SOIL.ABSORPTION SYSTEM (SAS): (locate on site plan,excavation hot required) If SAS not located explain why: Type . .......... leaching pits,number:_ eaching chambers,number: 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)., zAa CESSPOO'cesspool must be pumped as part of inspection)(locate on site plan) Number and configuraiont 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): r ' Comments(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation,etc.): PRIVY (locate on site plan) Materials of construction:. Dimensions: Depth.of.solids: Comments(note condition of soil, 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 PART C SYSTEM INFORMATION(continued) Property Address: 1. Owner: Date of Inspection: C-)WO 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. 0 Zn 7 rn / 10 Page 11 of 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY,ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C ` SYSTEM INFORMAI:ION(continued) Property Address:�,—_2_� ph AZU1 Owner: Date of Inspection: QQ�Jppj ,C;noa. 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 feet of SAS) Checked with local Board of Health-explain: Checked with,local:excavators, installers-(attach documentation) _VAccessed USGS database-explain: You must describe how you establ.islied the tiig'h ground water elevation: ? ` yek�W 11 Permit Number: _ Date: Completed by: � � HIGH GROUND-WATER LEVEL COMPUTATION z, \ Site Location:_ 9 6y hIV07 Lot No. Owner: I& 0 Address:. Contractor: / Address: l �!° p Notes: STEP 1 Measure depth to water table. to nearest 1/10 ft............... Date Z I month/day/year STEP 2 Using Water-Level Range Zone and Index Well Map locate site'and determine: C) Appropriate index well.:....... ............... .......... CB i Water-level range zone .................... . STEP 3 Using monthly report,"Current Water Resources Conditions" determine current depth to j A 'water level for index well ..................... month/year STEP 4 Using Table of Water-level Adjustments for index well (STEP 2A),current depth to water level for index well (STEP 3), and water-level,zone.(STEP 2B) determine water-level adjustment .........................:....................... ;`::., r. STEP 5 Estimate depth to high water by subtracting the water level adjustment"(STEP 4) from,nieasured depth to water level at site (STEP 1) .................... Figure 13.--Reproducible computation form.. 15 , AV A00® _ r _ I