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HomeMy WebLinkAbout0067 RENOIR DRIVE - Health E67 RENOIR DeOSTERVILLE a= PL1 7 a a L No............. .::21 Q Fxs.............G................ THE Ce1MMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH [��.y"' ....-.....OF...................� ....................... Applirnfion for UWVoiial Workii Tomitrnrtion rantit Application is her made_for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: �.......... ..................�w���------....J�....n....._..... �� 51..................... .. Location Address Lot No. ......................................... i4 •� �. _...._ '�� ....... a. . .......�...: U.................... Owner Address .............................................. �<'� s:............ . ._..._..--------- �.... ................. Installer Address UType of Building Size Lot........... .........Sq. feet Dwelling—No. of Bedrooms...______________/_?_.______________________Expansion Attic (A-�b Garbage Grinder (Ai)j '4 Other—Type T e of Building No. of ersons____________________________ Showers GL YP g ---------------------------- P ( ) — Cafeteria ( ) Q' Other fixtures _.._... W Design Flow.......................5--Y___..gallons per person per day. Total daily flow..__..._._.__.__:.J..�__('..............gallons. WSeptic Tank—Liquid capacity.t.�_U(gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width____._._.._.__._.___ Total Length.................... Total leaching area....................sq. ft. Seepage Pit No_____________ _______ Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box Dosing tank ( ) a Percolation Test Results Performed by--•---•••-••-•••••••---•-••. i�G/ � e?�' T ........ a Test Pit No. 1..... C.S- minutes per inch Depth of Test Pit__._1_j? ...... Depth to ground water....41-1 ;t. (% Test Pit No. 2......___ iinutes per inch Depth of Test Pit.................... Depth to ground water........................ ------------------------- •..--•--••----•-•- ._. ._.4... --••--..............•. ____----- O Description of Soil---------•-•------------------•--.......------1............................................. -0�`z'-- "t<v/�SQi ��l ..�' !-I_ �,n....- .--_ ------------------------- UNature of Repairs or Alterations—Answer when applicable............................................................................................... -----------------=••••••_._...--••••••-••••••••--•••----••-•---.._..-•-_.____._••-••-•-.._................_.....••••••••••-••••••---••••••••-•------•-•...--••-•-••••••••.__._•••...__........•••--_.._. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State 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 lth. Signed.................. - .� ..� D t - o Application Approved By............... �. ... 1 Date Application Disapproved for the following reasons:................................................................................................................. ...........................................•--•---........................-•---.._.._..-----••-----•--.... . ••...••-- • --•._....-•--- Date PermitNo......................................................... Issued...................................................... Date ............ r No................ r... �J FRs............. .... THE COMMONWEALTH OF MASSACHUSETTS ' BOARD OF HEALTH - ' U11(..t-.y'..............OF.................. /nt 6°`�r ll. ° Appliration for Biiipuattl Workii Tonstrnrtiun ramit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: .....---•...................•---....`...�........--�`.r................................. ,............................. .............. Location-Address �° Lot No l_ /` {,�s .....--•-•-.............................C, � r' ."r ..L_ .1....._��� .........................--•--.....O.Q.-i........... .�.Li........�t..... � L Owner at, % Address +� r!'!t! /l f•� ty ,+ .............. Installer Address U Type of Building Size Lot..... .J. �t .S..L.._._Sq. feet Dwelling—No. of Bedrooms................ ?---------------------Expansion Attic ( A! b Garbage Grinder (k)o aOther—Type of Building ............................. No. of persons............................ Showers ( ) — Cafeteria ( ) d Other fixtures .._..-- W Design Flow........................5.. ..gallons per person per day. Total daily flow ..............•----•-•.............----•---•-••-•--•-•---.........---•--......---•-........ .Y.. .................J..J..C3..............gallons. WSeptic Tank—Liquid capacity..j�t?.S,allons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area--------------------sq. ft. Seepage Pit No---------_--_------ Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box Dosing tank ~' Percolation Test Results: Performed by............................. � �. ! Date........ G le!... ,Wa Test Pit No. I._... :,S:�minutes per inch Depth of Test Pit..... _: __. Depth to ground water..: ya. .. 44 Test Pit No. 2........._; Iinutes per inch Depth of Test Pit.................... Depth to ground water........................ R' ------------ '...., O Description of Soil---------• "` ... ... ......+....� �e -- •----•.........••. V = ............................ W ----------- � / - U Nature of Repa��e�—Arrfwef fi�hen applicable.---------------- -------- •--------------------------......---------...-'-•------- -----------------•--------------------•----•------------------..._......------------............•---..•-• Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 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. r Signed.................. ....... ..........z,/,,S� s Dater Application Approved BY / ...a................................... / D � Application Disapproved for the forming-reaso s:_.. /_:_..'............. ...•-------- ---------- ----------•-----•--••................•----•--------------•-----------•--...-----.._.........•......-----•--"-•-...__.......•••--••----•-•=--•....•-•--•-•-•----•---•••--'----••---•....---••-•---.----- Date PermitNo......................................................... Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...`.'"A: ...OF..........� j ���. ,r,fir �.................... f (Ipdif iratr of Tuntplittnrr THIS IS TO CERTIFY, That the Individual Sewlrge Di p sal System constructed,"Jor Repaired ( ) Installer at. -0--�f •-••F---- ---•-----•-- w ..T,�.t �; -./."............... ---� ----------------- has been installed in accordance with the provisions of-TITLE; 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No_____ __ ________•-_.--•---••••-..--.- dated................................................ THE ISSUAN E O THIS CERTIFICATE SHALT gEC,ONST U AS A GUARANTEE THAT THE SYSTEM WILL N Ip SATISFACTORY. DATE..... 6. .._ .. .... .................................. ..---- Inspector. .... .......................................................................... i THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 1... ..+. !�-........0 F........................ ' Gl .S f/� /.'�................ No..-,,` _... FEE............e.1::..... RIV41011ttl lvorkg Tonntrnrtion rMit Permission is hereby granted.............................. _ff`j..............] } to Construct (d) or Repair ( ) an Individual Sewage Diss sal System i ) atNo.......................................&'�_....... ' / ti` ` C. { ;- 1 Street as shown on the.application for Disposal Works Construction Permit No..................... Dated.......................................... � I ------------------------•---•......-••.••�----�-........................ ................................ DATE. /- 1--- . f --- 4 : ��`�ard of Health FORM 1255 A. M. SULKIN, INC., BOSTON ' - M - < $ �' i ado-.� s t.'a"s ` ,a 3'�•5:. ni -Tir 31 'A 't>� r(F ! IAF ty 4E- Ik SA "R Nlc 1 ( 0 Al W' v0 r u; R S �(AYN. 07, 7a �fLin,G �V� Y C7pi. F'r ^i1�?' �4 , ?1`, B v a d ,t vn- 4. 2. 30 `© 4A,OF _ /�D IJ 4' .�A r.J�", rpm�• � +a .�^T r .% . aU f�f�on1T• � sr r3* AL MORSE a _ o� p�ND.10951��Q NAL•Ea�O\ , LEGEND , . EXISTING SPOT ELEVATION Ox0 }~ ?tiA�s�°f°s, CERTIFIER. , PLOT PLAN EXISTING CONTOUR --- p v K R06ERT. FINISHED SPOT ELEVATION eRucE", FINISHED CONTOUR 0 t°,$`7� / ,✓/t L. r ELDR.S r J I APPROVED , BOARD OF HEALTHra�®� DATE AGENT „ { . Y SC s ALE l o DATE__ TE G LDREDGE ENGINEERING CO /N �R �✓ ' '�� C.I.IENT.. 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L,,d .1, •t. .;�'}:}�+:. r!� x�e`:%'i�, a".^r,{,.�'.3 '±C, .,�4t {ia �:FL +lt..� :,.M .^.: .'J O.- Y' Naika k:, .. ,.. J a'.7�w 'i.,.:i,x• '�' e'' .i,�1 p r, .ti �l .,r:: J. CO.K.NIO'WEALTH OF MASSACHUSETTS > 1. EXECUTIVE OFFICE OF ENVIRONMENTAL AFF��IPS DEPARTMENT OF ENVIRONMENTAL PROTECTION. ter(' OE BOSTO DLL 0210c 61'i 292-5NRN 5( ' . r ?oi►o" ;RL oxz a HEA( o�Sf,�� e•reta-n ARGEO PALL CELLUCCI do DAB TR:.'HS Governor C tnmissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM, PART A . CERTIFICATION Y Prop"Address: 67 Renoir Dr . , 0stergi11ENameof owner A . Cameron r� Address of Owner: Date of Inspection: Name of Inspector:(Please Print)Wm. E .- Robinson Sr-. I am a DEP approved system!inspector rsuamt to Section 15.340 of Title 5(310 CMR 15.000) CornpanyName: Wm. E . Robinsoneptic Service Mar'IingAddress: PO BOX 10 9. Centerville , RA Telephone Number: 7 _ 7 7(� CER71RCATION 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 inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site se ge disposal systems. The system: Passes Conditionally Passes Needs Further Evaluation By the,Local Approving Authority _ Fails Inspector's Signature: 3� Date. �'O The System Inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)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 tfte system owner and copies sent to the buyer, if applicable, and the approving authority. `. NOTES AND COMMENTS e r . revised 5 2 9.8 Page l of 11 • M , i� .rted on Reward Panrr' w SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) t "ropertyAddress:. 67 Renoir Dr . , Osterville ,)weer: A . Cameron Date of Inspection� 3a^g INSPECTION SUMMARY: Check A, B, C, or D: A. SYSA PASSES: t"' I have not found an information which indicates that an of the failure conditions described'n Y Y c d i 310 CMR 15.303 exist. Any failure criteria not evaluated are indicated below. COMMENTS: C B. SYSTEM CONDITIONALLY PASSES: ' One or more systern 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. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If "not determined', explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or the septic tank, whether or not metal, is cracked,structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. 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 jwith approval of the Board of Health): broken pipe(s) are replaced obstruction is removed revised 9/2/98 Page2of11 I ,-k SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM _ PART A CERTIFICATION(continued) Property Address: 67 Renoir Dr . , -Osterville Owner: A . Cameron { Date of Inspection C. FUR ER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:. ' r Co ditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the pub is health, safety and the environment. ' 1) SYS WILL PASS UNLESS BOARD OF HEALTH DETERMINES W ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM IS N T FUNCTIONING IN A MANNER WHICH WILL PROTECT,THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of 'surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. . r 2) SYS M WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS FUN TIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a'private water supply well. The system has a septic tank and soil absorption system and the SAS 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. Method used to determine distance (approximation not-valid). 31 OT ER revised 9/2/98 Page 3of11F a. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM _ PART A CERTIFICATION (continued) Property Address: 67 Renoir Dr . , osterville Owner: A . Cameron Date of Inspection: D. SYS FAILS: You must in i ,ate either "Yes" or "No" to each of the following: I he determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this det mination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No 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 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 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. (7 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 analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. , E. LARGE SYSTEM FAILS: You must i icate either "Yes" or "No" to each of the following: T e following criteria apply to large systems in addition to the criteria above: . 7 T e system serves a facility with a design flow of 10,000 god or greater(Large System) and the system is a significant threat to public alth and safety and the environment because one or more of the following conditions exist: 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) The ow r or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office o the Department for further information. revised 9/2/98 PaRc4ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM, t PART B ' CHECKLIST Prop"Address: -67 Renoir Dr. , O'Sterville Owner: A . Cameron Date of Inspection: i Check if the following have been done: You must indicate either "Yes" or "No as to each of the following: Yes/ No _�/ _ Pumping information was provided by the owner,occupant, or 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. v/ The facility or dwelling was inspected for signs of sewage back-up. 4 I/ _ The system does not receive non-sanitary or industrial waste flow. _ The site was inspected for signs of breakout. _✓ _ . All,system components, excluding the Soil'Absorption System, have been located on the site:' ' _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles 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: v _ Existing information. For example_Plan at B.O.H. _ Determined in the field (if any of'the failure criteria+related to Part C is'at issue,approximation of distance is unacceptable) 115.302(3)(b)) V - The facility owner (and occupants,if differeni from owner) were provided with information on the propermaintenanro-of SubSurface Disposal Systems. t re:v, seQ Page Sofl] s „ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 67 Renoir Dr . , Osterville Owner:A . Cameron Date of Inspection: i FLOW CONDITIONS RESIDENTIAL: Design flow:`U d g.p.d./bedroom. Number of bedrooms(design): Number of bedrooms (actual) Total DESIGN flow re id b Number of current residents: Garbage grinder(yes or no):/LU Laundry(separate system) (yes or no);lam; If yes, separate inspection required Laundry system inspected (yes or no) Seasonal use (yes or no):/L 6 Water meter readings, if available (last two year's usage(gpd): 1998 90 , 000 gal. Sump Pump (yes or no)-.,�L,_v 1997 2, 000 gal. Last date of occupancy: / --16—g 1/ COM ERCIAL/INDUSTRIAL: Type At stablishment: Desile w: Upd 1 Based on 15.203) Basissign flow Grea present: (yes or no)_ Indusaste Holding Tank present: (yes or no)_ Non- ry waste discharged to the Title 5 system: (yes or no)_ Wateer readings, if available: Last f occupancy: OTHescribe) Lastf occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: � -9 2 System pumped as part of inspection: (yes or no)_ If yes, volume pumped:_gallons Reason for pumping: TYPE, 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) I/A Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components, date installed(if known)and source of information: �. Sewage odors detected when arriving at the site: (yes or no)/LU revised 10/2/9E Page 6(if ll . .e Ir SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM e PART C SYSTEM INFORMATION(continued) ' tropertyAddress: 67 Renoir Dr . , Osterv.ille' Owner: A Cameron Date of Inspection: BUIL IG SEWER: (Locate on site plan) Depth b low grade:_. Material f construction:_cast iron_40 PVC_other(explain) Distant from private water supply well or suction line Diamet r Comm nts: (condition of joints, venting, evidence of leakage,-etc.) 77 SEPTIC TANK: (locate on site plan) "9 Depth below grader Material of construction:�oncrete_metal` Fiberglass _Polyethylene_other(explain) If tank is metal, list age_ ls.age confirmed by.Certificate of Compliance_ (Yes/No) Dimensions: Sludge depth:_:: Distance from top of sludge to bottom of outlet tee or.bafflei Scum thickness:' Distance from top of scum to top of outlet tee or baffie:_� ` , Distance from bottom of scum to bottom of outlet tee or baffle:L� " How dimensions were determined: (� 7 i i✓ �d t� 1� ;omments: (recommendation for pumping, condition of inlet ayd outl tees o baffle;, pth of uid level in relation t outletinvert, structural`integrity, evidence of leakage, etc.) /9 � ��°=� GR SE TRAP: (locat on site plan) Depth low grade:_ a Material f construction:_concrete_metal Fiberglass Polyethylene,_otherlexplainl., imensio s: Scum thi kness: Distance rom top of scum.to top of outlet tee or baffle`. Distance from bottom of scum to bottom of outlet tee or baffler Date of ast pumping: Com nts: (reco endation for pumping, condition of inlet'and outlet tee''s or baffles, depth of liquid level in relation to outlet invert, structural integrity, eviden a of leakage, etc.) re�T� sed 5/2/98' Page 7oril SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) J,►openyAddress: 67 Renoir Dr . , Osterville 0wnef: A . Cameron Date of Inspection: TIG OR HOLDING TANK: (Tank must be pumped prior to, or at time of, inspection) (locate on site plan) Depth elow grade:_ Materi I of construction:_concrete_metal_Fiberglass_Polyethylene_other(explain) Dime ions: Capa ity: gallons Desi n flow: gallons/day Ala present Alar level: Alarm in working order:Yes_ No_ Date f previous pumping: Com ents: (con ition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX:IJ (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal, evi�deence�bf solids carryover, evidence of leakage into or out of box, etc.) - PUMP HAMBER:_ (locate n site plan) Pum in working order: (Yes or No) Ala s in working order(Yes or No) Cornents: (note condition of pump chamber, condition of pumps and appurtenances, etc.) 2 revised 9 98/ / Page 8 of 11 , SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM *7 PART C : i� SYSTEM INFORMATION(continued 6 Renoir Dr.toperty Address. 7 r Q 'ter V l l l e Owner: A . Cameron Date of Inspection: J?Lj_Q a k •✓// _ ;.:: u h �:, Via. SOIL ABSORPTION SYSTEM(SAS):_ (locate on site plan, if possible;excavation not required;location may be approximated by non-intrusive metFiotls) ... If not located, explain: .; n .• , Type: v leaching pits, number: leaching chambers, number:_ leaching galleries, number: �< .,, leaching trenches,number, length: leaching fields, number, dimensions: overflow cesspool,number' r a Alternative system` Name of.Technology +' ,r s Comments: r (note condition of soil; sigris'of hydraul failure; level f pond' d g, mp•soil,'condition of vegetation c.l ��� ix 'CEss OOLS:_ w r r � (locate n site plan) Number nd configuration: Depth-top of liquid to inlet invert: Depth of s lids layer. depth of s um layer: �� 0M Dimension of cesspool: Materials o construction: Indication groundwater, r y i low (cesspool must be pumped as part of inspections Comm en (note co dition of soil; signs of hydraulic failure, level of,pondirig; condition of vegetaUon,'etc.)'`; l PRIVY: t. �$ (locate o site plan) , Y Materials of construction r,> Depth of solids: Dimensions Comme s: ` (note co dition of soil, signs of hydraulic failure,'level of pondmg''`condition of vegetation; etc,) a 4 d "j, S 5•�, 7 '�` s1 Mw.' r� :.�' �rh �:� 41' 4f � t � k. E<' w revs°sue 7. 5 Li,7'_ x,g Page 9of11' +- f a 4 ` SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) l 'roperty Address: 67 Renoir Dr . , Osterville t. lwner: A . Cameron , Jate of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) F revised CJj 2�QR Page 10ofII r' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM` PART C' Ra r. SYSTEM INFORMATION Ieononued► *. �ropertyAddress: 67 Renoir Dr Ost� i`erville `$ „., Date of Inspection:Cameron SKETCH OF SEWAGE DISPOSAL SYSTEM include ties to at least two permanent reference landmarks or benchmarks locate all wells within 400'!Locate where public water,supply comes into house! ; t a 1 ti a x a r , F , , es :' : ' I F t� y,:•.f ,�'°! Sp 2. .try ai. r i .a � Mom,. r:, at�?- � l` i •� � +x� y _ � � I - e e ,k ! revised 9J2/9 ` PaRc 10 0[I ' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM 1 t SYSTEM INFORMATION(continued) rdp"Address: 67 Renoir Dr . , Osterville .. �' , '• , Owner:A . Cameron Date of Inspecd*n� NRCS Report name Soil Type_ s P : Typical depth to groundwater *` USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to GroundwateritU Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observed Site (Abutting property, observation hole, basement sump etc.) Determined from local conditions w Checked.with local Board of health Checked FEMA Maps _Checked pumping records , Checked local excavators, installers Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) revised 9/2/98 Page ttortt