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Home My WebLink About0069 RENOIR DRIVE - Health 69 Renoir Drive, Osterville %r F r C . o k. i G r o _ _ --- --------- J 0 o 20� V: o = �' 3z3 �/. _ cc 00.� o � 8 21 q 6 �ar9a y / _ / J as / 3 S-M N f r�;� i D N I a� II 1 1 oo Bs N 1� as X s t4 o O m i I it m m o 0 7G 2 T O T '^ % m v oo £ O C PT7 czi T y CD �� Z ~ v AOr'n n = A c T B m mo�'o m � rii C � � Z G� � � �0 70 .M• 2 A y. N x -1 �L � 0 aOc z A c m m A < A < 3 T N T N a v w1�sr�irs a�' ��— � � � �� t �a ��` �� _ � � q ��,o- ��.we > o � 3 g $ N r A N v.- s r. � � �� s • a 40 v v N O F r" AF /A 40 A 39 CTr Z A 1 v l `� �� '\ �� .. �� T�� -,` �_ No....P.. ._.3�® Fps..... ............... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEA T _........'}�� ..�............OF................13... ...............: --------.........._..-------- Appliration for Biiipasal Works Tonstrurtion rrmit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at ---------------•--------.............. `� ...,iv r� 5 /.:..............•-_.. ... .. ... ............ Locatio Address or Lot No. - ....--••--•-•-•------........................ .,n. ......... .0 ......................_.. ,l ca. ... ) 4 - --....Y �. Owner Address at ,2.f s..c,e r ---------- •------------------- '........ Installer Address Q Type of Building Size Lot_._ ....Sq. feet U Dwelling—No. of Bedrooms...............3--_____--------.__.------.Expansion Attic Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) 04 Other fixtures ..._ dr-.. --------------- ------------- W Design Flow..........................`5..5..........gallons per person per day. Total daily flow................3-T A_................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 tank '"'` Percolation Test Results Performed b /. .......... ........ _ Date............ a y- . :_.. j..... Test Pit No. 1......� '. 'minutes per inch Depth of Test Pit...... ...4i?.... Depth to ground water---. 44 Test Pit No. 2.-------4 e... Minutes per inch Depth of Test Pit....-................ Depth to ground water........................ . --• ..... ••. • ---- --- ----• -- ---• .......... -----••- o Description of Soil................................................... w ----------------------•---------•--------....._......------...•------------•-•----...-------� _-- ------ s x •--•----------- --------------------------------------------------•. ----•-------••-•----------...--------------------------•--•----•--------•...----------------------.....-------•--•--•--....... 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 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. /i,gn --...... �.. �£_Application Approved By--•-•• •_- ........................••-----------------•-•-----.........••. e� ...._._ Date Application Disapproved f r e following reasons:-------•----------------------------•-....--•-----..._.....---•--.............................................. ..... ................................................-.................................................................................................................................................. Date PermitNo...........................................-............. Issued...................•.................................. Date No....Tj..J.r�. FRic ........................ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEAK _rI I ...................0 F................ 13 ..4........A................................................... Allpfiration for Uhipasal Hlorkii Tontitriartion "punfit Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal System at: ........................................ ............................................... . ......................................................................... Locat* Address r Lot No. ...... ............ ............. ............................................ ........ .1.4...........L wnerwj Address ,., ..r—A.1............................................../...................................... ................... .............................. Installer . ..... ...... Address Type of Building Size Lot.. ....Sq. feet Dwelling— No. of Bedrooms...............3:-_-----------_---------Expansion Attic (A.,V Garbage Grinder aOther—Type of Building ............................. No. of persons............................ Showers Cafeteria Otherfixtures ---- ............................................................................................................................... Design Flow...........................!Lr .........gallons per person per day. Total daily flow................7-TA................gallons. 1:4 Septic Tank Liquid capacity............gallons Length................ Width.........._..._. Diameter._._.___.__..... Depth................ Disposal Trench—No. .................... Width_....___....__.._... Total Length............-...._.. Total leaching area....................sq. f t. Seepage Pit No..................... Diameter.................... Depth below inlet.._................. Total leaching area..................sq. f t. Z Other Distribution box ( ) Dosing tank ( ) or Percolation Test Results Performed by...... /40 Z�.J�T ...... ........ ... ...•.............. .......t7v.... Date...____...._5 Test Pit No. I......�.'?hninutes per inch Depth of Test Pit______ Depth to ground water.._._ Test Pit No -�inutes per inch Depth of Test V-0-0t,V* 2........4.6. .ft st Pit.................... Depth to ground water........................ ..................................... ..............................t......... Description of Soil........................................................... 'C .............r..........0.'-I�--I......................... - ------- ------------------------------------------*---------------:.......................... 2........... ....... --------------- ............................. -------------------------------------- --- U Nature of Repairs or Alterations *----------*-----------------------------------*---------------------------- ..........--------------lterations—Answer when applicable................................................... ............................................ ........................................................................................................................................................................................................ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of T I T 1Z 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. /ign. .......... ...... ........ .�....Sf . e ApplicationApproved By.............. ....................................................................... .... ... . ..................... Date following Application Disapproved folr e following reasons:................................................................................................................. ........................................................................................................................................................................................................ Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEAL ...............OF............. ................................... (Intifiratr of Toutplitturr THIS IS TO CERTIFY, That the Individual Sewage� Disposal System constructed- �or Repaired by................................................ ............P.4.16...t...1-0/t----- ......................................................................... Install, at......................... .......................... .. ...... ..........I......i. ....r; /(...... ---------- R .. es ribed in the has been installed in accordance with the provisions of TITL, 5 of The State Sanitary Coodjo�a 'es application for Disposal Works Construction Permit No-Y.3.�%n�7............... dated._.. ..................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE._............................�11L ,r.j� ....................................................... ........................... Inspector.......12..IA THE COMMONWEALTH OF MASSACHUSETTS BOARD OF, HEALTH No.02...A;7 ............7.-J.. .W_ .....OF................... .1.f.'0.0.0?A) ....................... FEE....................... Permission is hereby granted....................................3... ------e.j ..................................... to Construct (1-4 or Repair an IndividuA ewage Disposal ....:4.. ............ at No.................................................. _Z Street as shown on the ppli/tion for Disposal Works Construction Permit NQ ............. Dated. ................ . .......................T....................................................... Board of Health DATE.------- ....................................................... FORM 1255 A. M. SULKIN, INC., BOSTON � VL' 00 , 39 N' ' f f a J } � ,Y z j ob LA �. 6'x 0 J ro• , Mn�' '„� 1 L�H 0 Mq of BE '�� J .�s�9 1 /SO o BRUCE v �MORSE N ELDREDC �� 'v�/C� //rj No.109514Q .p f, ¢ � h•V 9p �G/STEP ��`' FFSSlONAk- ` LEGEND EXISTING SPOT ELEVATION Ox0 CERTIFIED PLOT PLAN k IrXIST16tieG CONTOUR ---- p. ---- Eau �u Z-o -r 2 7-773 1-7 j7<', Fi�IISHI=U SPOT ELEVATION Z rr FINISHED CONTOUR 0 �I_ _� _ � APPROVED BOARD OF HEALTH ��3��1:� �'.,��.�,�� ► _DATE -- AGENT SCALE, / 4 * DATE C7i DGE ENCl�fEE lP��.CO. !N __ �.___� CLIENT I CERTIFY THAT THE PROPOSED REGISTERED JOB N0. °�22-a 6 BUILDING SHOWN ON THIS PLAN CIVIL LAND CONFORMS TO THE ZONING LAWS � DR.BY� �. rd-1.1'ci°�GINEER SUrdVEYO 4' OF BARNSTABLE , MASS. M 712 NiAI N STREET CH. By ' - t HYAWNIS, MASS. SHEET 2 - -� _.L. 0F D TE. REG. LAND .SURVEYOR 20 FT M!/V. G/T ARE MORLf THA:'J /2"EELOAV t 14 24'O/AMETEK COyCRETE COPE ' �. SNALL BE ,SROC/GHT TO GRADE. �•;,v EXT,�q s `►° — CONCRCTE 4'PYC P/P� X0E,4vy CAST /RO/Y 4=0{/EI?. .S"Y,4.LL. OE uSEJ ELc✓' 44.Lp coYE/GS /B P DR/vEyi/A y 2�r M/N. CD/VC•RE TE Cr, .wE Cd P, CL EAtV .SANG i gCxF/L4. 'LAYER ' _ ' QF �Ie _3/19 Ml1V P1TCM A :`�/4L.. ' 1 • • a: 46 • r.r s •4 WA SHEO 570,V— %' S,EPT/C TANK D/ST. • � • • • • • • o0 BOX a � . � • � 8 • v • fill .•� }r • • '~ • too DEPTH • • s • • •0 WAS)iEO STONE 7� x �,0. • a•.• r • • • • • •r p ,•• PREC,45T SEEPAGE em}L�r1�6/l' s •• r • • • • • r• r • o P/7 OR EQV/V• l Ji/E/L'RT CL EVAT/0/V 1 INVERT..4T e4//40/N6 3 e:0 FT G D/AM. 3. /D FT APIAI- C(SEF WWULATJON). INLET .SEPTIC- T,4NK F7.'' OtlTLET: SEPTIC rANAC 16 3 Fes' VD i /NGET D/STR/8(/T/D/Y 80X 4 FT: GROu TER TAQLE ION.of __ . 4tJTlETD/JTR/Bd7YONBCX 'c4..b � ,. tAf4E.T'L-ACMIAW fPIT SE'yt/A.GE: OlSP4�SA L SYSTEM -rASMATIO.N L EACH!/VG J P!T > D.ESIGJV CR/TFR/�l scwt� T v/�.FlVs/oN S F DIMENSION' C�_FT.!`►'w. N�Jf/0ER OF'dEDRO.OMS 'J 3� .' - •, G4RaAGE'D/SP05AL.uHlr t�oty� SOIL. LOG TOTAL ESTIM4r4FD FLOM/ 3 3 o 09.4L./A4V SOIL TEST ,*/ $O/L TFST,*Z SOIL TEST NUMSER C1F LEACMlNG P/TS__�_ 1-e Ec& 3 ZD �ftl�Y, pATE OF SOIL TEST . IST. .ACIN E ! OZ I / ESSED 5Y✓f t I/Ac_o 3S/OEL t . 7� PER COL AT/OV AATS,dtl LESS M//V/INt�f y TOTi44 LL+ACH//YG AREA SQ, iT. PENCOLAT/ON RATE Ik2 RPSERtiE4EACNlN6AREA t Z Of MA 'c �CNuFM� ^h -17 /o ROBERT c5 ALB T BRUCE i 'r 8 / N o - rn ELORE � ^�M14GFSE � 7/ jj A o No.10951 0 EL DREDGE L�NGIN.FER/NG CO,/NC. C'I TEE 04�. �'O SST ��ti L Y, 0, 0 7/2 MAIN S;r , AIY.4NN/S. M4S3, `Q SBR`1 �Fr `�\Ss� IVO GROUND Yi�i4,TL`R.1�/VCOIJ/VTERE� Prrt'N!3 lL{•' ``� Q GRO[J/V0. YvATE�P AT ELEf/ - .IOB NO: 2zc7 SHEET OF I . Commonwealth of Massachusetts. Executive Office of Enviromnental Affairs Dept. of Environmental Protection ,Jolm Gi Ad One winter Street,Boston,Ma. 02108 D.L.P. Title V Septic inspector P.O. Box 2119 Teaticket, MA 02536 (508)564-6813 WILLIAM F.WELD �f � / � - Governor ARGEO PAUL CELLUCCI Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 69 Renoir Dr.Osterville r---CST �`� Address of Owner. Date of Inspection: 216/98 (if different) ff Name of Inspector: John Graci 1998 1 am a DEP approved system inspector pursuant to Section 15.340 of Title%(310 CMR 15.000) I�wNOF Company Name,Address and Telephone Number: H0(>Hp plrAB(E CERTIFICATION STATEMENT ., I certify that I have personally inspected the sewage disposal system at this address and that the information repo rted.b.elow is4r• e, 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 sewage disposal systems. The system: X Passes This Inapection Is based on criteria defined In Tftle V code 310 CMR 16.303.My findings are of how the system is _ Condit' no lly Passes performing at the time of the inspection.My inspection does Needs F th Evaluation By the Local Approving Authority not Imply anywarrantyor guarantee ofthelongevityofthe septic system and any of Its components useful life. Fail/ubmit Inspector's Signature: Date: 2191a8 The System Inspector shall a copy of this inspection report to the Approving Authority within thirty(30)days of completing this inspections. 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 A, B,C,or D: A] SYSTEM PASSES: x I have not found any information which indicates that the system violates any of the failure criteria defined as in 310 CMR,15.303. Any failure criteria not evaluated are indicated below. COMMENTS: 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 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 ex(iltration, or tank failure is imminent.The system will pass inspection If the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 04127)97) One Winter Street • Boston,Massachusetts 021108 • FAX(617)556-1049.• Telephone(617)292-5500 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 69 Renoir Dr.0sterviile Owner: Robert Date of Inspection:216199 _ Sewage backup or.hreakout or hioh.static Water level observed.in.the distribution box is due to a broken. or obstructed pipe(s)or due to broken,settled or uneven distribution box.The system will pass inspection if (with approval of the Board of Health). Describe observations: broken pipe(s)are replaced obstruction is removed distribution box is leveled 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 C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the. system is failing to protect the public health, safety and the 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 of water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone 1 of a public watersupply 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 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 presense of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method usedto determine distance (approximation not valid) 3)Other D] SYSTEM FAILS: You must Indicate either"Yes"or"No"as to each of the following: _ I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination 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 in 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 cesspool. SAS is in hydraulic failure. (revlsed 04117)97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 59 Renoir Dr.Ostervllle Owner: Robert Date of Inspection:V6198 D]SYSTEM FAILS(continued) Yes No 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). Numbers 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 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. 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 indicate either"Yes"or"No as to each of the following: The following criteria apply to large systems in addition to the criteria: _ 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: Yes No _ the system is within 400 feet of a surface drinking wafer 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 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 04127)97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECLIST Property Address: 69 Renoir Dr.Osterville Owner: Robert Date of inspection:216198 i Check it the following have been done:You must indicate either"Yes"or"No"as to each of the following: _(_ Pumping information was requested of the owner, occupant,and Board of Health. x None of the system components have been pumped for at least two weeks and the 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. x As built plans have been obtained and examined. Note if they are not available with NIA. .x _ The facility or dwelling was inspected for signs of sewage back-up. x — The system does not receive non-sanitary or industrial waste flow: The site was.inspected for signs of breakout. .. , x All system components,excluding the Soil Absorption System, have been located on the site. x 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. , x The size and location of the Soil Absorption System on the site has been determined based on — — The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub-Surface Disposal Systens. x Existing information. Ex. Plan at B.O.H. — — t Determined in the field(if any failure criteria related to Part C is at issue, approximation of distance is x . unacceptable)[15.302(3)(b)] k' (mleed 04117)871 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART.C SYSTEM INFORMATION Property Address: 6g RenolrDr.Osterville Owner: Robert Date of Inspection:216199 FLOW CONDITIONS RESIDENTIAL:Design flow: 330 g•pd/bedroom for S.A.S. Number of bedrooms: Number of current residents: 2 Garbage grinder,(yes or no): No Laundry connected to system(yes or no): Yes Seasonal use(yes or no): No Water meter readings,if avail able:(last two(2)year usage(gpd): nfa Sump Pump(yes or no): No Last date of occupancy: nla COMMERCIAL/INDUSTRIAL: Type of establishment: nla Design flow:0 gallons/day Grease trap present:(yes or no) No Industrial Waste Holding Tank present:(yes or no) No Non-sanitary waste discharged to the Title 5 system:(yes or no) No Water meter readings,if available: nra Last date of occupancy: nra OTHER:(Describe) Na Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: late pumped 3 years ago System pumped as part of inspection:(yes or no)No If yes,volume pumped:n gallons Reason for pumping: rVa TYPE OF SYSTEM x Septic tank/distribution box/soil absorptions system Single cesspool Overflow cesspool Privy Shared system(yes or no) ( if yes, attach previous inspection records,it any) I/A Technology etc.Copy of up to date contract? Other: - APPROXIMATE AGE of all components,date Installed(if known)and source Information: t0 years E Sewage odors detected when arriving at the site: (yes or no) No (revised 04127197) r— V SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPEC TION FORM PART C SYSTEM INFORMATION (continued) Property Address: 69 Renoir Dr.Osterville Owner: Robert Date of Inspection:215199 I SEPTIC TANK: x (locate on site plan) Depth below grade: 6" Material of construction:x concreate_metal FRP_Polyethylene_other(explain) If tank is metal, list age o Is age confirmed by Certificate of Compliance No (Yes/No) Dimensions: Le•e^He7^w4•10 Sludge depth:2" Distance from top of sludge to bottom of outlet tee or baffle: 25 Scum thickness:1" Distance from top of scum to top of outlet tee or baffle:6" Distance form bottom of scum to bottom of outlet tee or baffle: 17" How dimensions were determined: measures { 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.) Septic tank and all components are structurally Bound and functioning property.Recommend pumping every one to two years. GREASE TRAP:_ (locate on site plan) Depth below grade: rda Material of construction: _concrete_metal_FRP_Polyethylene_other(explain) Dimensions: rya Scum thickness:rVa Distance from top of scum to top of outlet tee or baffle:rda i Distance from bottom of scum to bottom of outlet tee of baffle:-rda Date of last pumpingnt_ 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.) nfa BUILDING SEWER: (Locate on site plan) Depth below grade:jr_ r Material of construction:_cast iron x 40 PVC_other(explain) Distance from private water supply well or suction lineto- Diameter: 4°_ Qmments:(conditions of joints,venting,evidence of leakage,etc.) (revised 04r17)87) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 69 Renoir Dr.Osterville Owner: Robert Date of Inspection:216198 TIGHT OR HOLDING TANK: (locate on site plan) Depth below grade: Na Material of construction:_concrete_metal_FRP_Polyethylene—other(explain) Dimensions: n1a Capacity: nla gallons Design flow: rva allons/day Alarm level:_nla Alarm in working order?_Yes . No Date of previous pumping.-- Comments: (condition of inlet tee,condition of alarm and float switches,etc.) - DISTRIBUTION BOX: x (locate on site plan) Depth of liquid level above outlet invert: Liquid level with bottom ofpipe Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box etc.) D$ox Is structurally sound. t PUMP CHAMBER: (locate on site plan) o Pumps in working order.(yes or no)No Alarms in working order(yes or no)_Ye: . Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) nla peYleed 114127l97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 69 Renoir Dr.Osterville Owner: Robert Date of Inspection:216198 SOIL ABSORPTION SYSTEM (SAS):x (locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods) If not determined to be present,explain: rda - Type: leaching pits,number: leaching chambers, number:Wa leaching galleries,number: Wa leaching trenches,number,length: rda leaching fields,number, dimensions:Wa overflow cesspool,number:Wa Alternate system: nla Name.of Technology:_rda Comments:(note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.)' System and all comoents are structurally sound and functloning properly.System now has 3'of water In It. CESSPOOLS: (locate on site plan) Number and configuration: rda Depth-top of liquid to inlet invert: rda Depth of solids layer: nla Depth of scum layer: Wa Dimensions of cesspool: Wa Materials of construction: We. Indication of groundwater: Wa inflow(cesspool must be pumped as part of inspection) nfa Comments: (note condition of soil, signs of hydraulic failure,level of ponding; condition of vegetation, etc.) rda PRIVY: (locate on site plan) Materials of construction: Ne Dimensions: Na Depth of solids: rda Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation, etc.) . rda (revised 04127197) I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) 69 Renoir Dr.Osterville Robert 216198 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references, landmarks or benchmarks. locate all wells within 100'(Locate where public water supply comes into house) } • j �ron o A b 44 � 3y b � 33 IJPI � G G OC 5� O c ek& p f-- Pay ! of 10 (revla+d MUST) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 69 Renoir Dr.Ostervllle Robert 216198 Depth of groundwater 12 Please indicate all the methods used to determine High Groundwater Elevation: Obtained from design plans on record. Observation of Site(Abutting property, observation hole, basement sump etc.) Determine it from local conditions Check with local Board of Health Check FEMA Maps Check pumping records Check local excavators, installers x Use USGS Data Describe in your own words how you established the High Groundwater Elevation.(MUST be completed) USGS maps and charts 4 . r t (revised MUST) page 10 a[ 10