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Home My WebLink About0119 STONE HORSE ROAD - Health 119 Stonehorse^Road Y '1 Ost&Ville.-t•P. A' = 142 081: 1 i 4e5 0 / THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: V Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Zipphratiou for �Dtgoar 6p!5tem Con5truction Vernait Application for a Permit to Construct( )Repair(K )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. CUJ Owner's Name,Address and Tel.No. Ass s9s s4ao azP,c OrSe Rd. , Kathleen Stearns le Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Wm. E. Robinson Septic Service P O Box 1089, Centerville Type of Building: Dwelling No.of Bedrooms 4 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 sand Nature of Repairs or Alterations(Answer when applicable) Title-5 septic system con— sisting of a 1 , 500 gal. tank, D—box and 3 precast leach chambers with stone a around. Date last inspected: 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 issued by this B ar ea h. Signed � Date Application Approved by Date Application Disapproved for the following reasons Permit No. � �°' Date Issued w �.0 A-J' %,a �. Fees q V F:rNo. THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Zipplication for Mtpooaf *p$tem Con.5truction Permit Application for a Permit to Construct( )Repair(X )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. Gi/ Owner's Name,Address and Tel.No. As e9r sS4agpaPgorse Rd. , Kathleen. Stearns Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Wm. E. Robinson Septic Service P 0 Box 1089, Centerville 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 t -iT�ipe-of S.A.S. Description of Soil, sand Nature of Repairs or Alterations(Answer when applicable) Title-5 septic system con- sisting of a 1 ,500 gal. tank, D-box and 3 precast leach chambers with stone all around. Date last inspected: "IN 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 issued by this B and ffHeal.h Signed L L4Date OZ 7�Y3 Application Approved by / Date _ Application Disapproved for the following reasons ' Permit No. Lf /A Date Issued 1 f T THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Stearns Certificate of Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired( X)Upgraded( ) Abandoned( )by Wm. E. Robinson Septic Service 1. at 119 Stonehorse Rd. , Ceitgtesw� (�)C;7 V —has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit 0 dated `'"2T" 'X!d Installer Wm. E. Robinson Sr. Designer The issuance of tys permit shall not be construed as a guarantee that the system will functio j as designe—d.- Date ( !,)I Inspector ti / -p— f ---- —r--- -- -- -- ' No. �"' T'� v',� — =— Fee$5 0 THE COMMONWEALTH OF MASSACHUSETTS Stearns PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS lizpooal *pztem Construction Permit Permission is hereby granted to Construct( )Repair(X )Upgrade( )AbandonnC), System located at 1 1 9 Stonehorse Rd. , C�az# yL-eV�l/ 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:Construct on m st be completed ithin three years of the date of this pe." its Date: t nl C Approved by % ( . TOWN OF BARNSTABLE . LOCATION F I koiAU SEWAGE # -0�01 p '-( IVMLAGE 6'1 -Eeo :,,j (I C ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO._� [N �,,:� S&Q+ 7`75-27 7G, SEPTIC TANK CAPACITY t S C9 0 LEACHING FACILITY: (type) gUt&X-1(S:, (size) I.- 3 — NO. OF BEDROOMS / BUILDER OR OWNER {-(- 4; 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 leaching facility) Feet Furnished by � � __ _ I � � /3�C�- v� Flo�S E �� - � -- Eck � ( 9 �� I � • � ��` ��` � �® S �.' � p 0 1� �: r� 4 TOWN OF BARNSTABLE LOCATION /� �= 1*;e5L 4eb SEWAGE # r�'� '- o VILLAGE 057- ASSESSOR'S MAP & L6T .INSTALLER'S NAME fa PHONE NO. A & B CANCO 775-6264 SEPTIC TANK CAPACITY ( 7) l �4poC S' LEACHING FACILITY:(type) (size) NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OILCWNER� L.;;,— DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No R�A� � � ,� �3 � �►t ® �� Ss� ��' uw� - �1�iQTiCE_`'Phis Fwm Is To Re Used For the Repair Of Failed - Septic Systems Only. CE1�'t'II�i_G__TION OF AZiD aYYI.ICaTi01�i VOR A DISPOSAL WORKS CONSTRUCTION PPRMff(WCfHODT DESIGNED PLANS) L William E. Robinson,S%cmbycoufYdmL the applicationfir dmposal words coa�nsoQon 4e*nma ss�d hY me datr� � `��" CY"� .concerning,tttae QY beater!at 1 1 9 Stonehorse Rd. , Centerville meeu all of the following criteria: • TN faded S)rstem is taaoecod tea ratidomd dwe"ady_ T1mc are no comumacwd or busneas vvi6th the dig. - I t is-E—dfiiod as C-scss Iand ame peteotanm me isless thm or equ a io 5 tnirwucs per inch rc no watandsvridiM 100 feetof the puaposcdsrpMk*mcmact no p WAC wdb�U0 M of the PraQosed Septa:s}-eni is no iucromm in Gm asdlaa chmm in me pmpostiare n�o variances racted or needed.osom of dee fig Ott aM&he teemed 1es�n fine��the nm� dmuoti[�Im tier gtaaredumter table using the Fnmplor mod when apti It the Z?t_S_wiH be kawd wi&250 in of ae}rea=tcd wetbndk rise b000m of the proposed trdehing fadlay will M be Located less than farrtoae{14)fact abom the mat mtm adffime d guandwncrowdoadw i the bgmmrIv A) Tote of Gmmd Smdbee - oks-MR G1S iuiosmaticm) . H I G.W.Fhtration t tllt MAX. tfio G W DIFFERENCE BETWEEN A 3ed S SIGNED:/V t,�; DA - fskffXa pad pblk O,SyUM on backi_, y:b-mMfiddw cn a R J � 1 a TOWN OF BARNSTABLE L LOCATION 10 S4eyuF once, P,ot4C) SEWAGE# 0001 KQy VILLAGE 1 ASSESSOR'S MAP & LOT-142_091 INSTALLER'S NAME&PHONE NO.—R017r ySQL,,J -7`75-27 7G, SEPTIC TANK CAPACITY 1 SO 0 LEACHING FACiLrTY: (type) u-x ((S, (size) NO. OF BEDROOMS BUILDER OR OWNER f< �. PERMrrDATE: COMPLIANCE DATE: Separation"Distance Between the: A 6 2 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 leaching facility) Feet Furnished by U kouSE Eck ` I EtI � D R; (� 3o�IS Gi��n— /i1e-i4i l✓vim G/ok/d in O ,q-6ove '`vt� f} �n,k� �aa�, cJ 6kT aF �..A-bbin16 �� l�vu� �ov� : � • C�R I^ VIL I l 44qkL-4Q_ l ' v tl IT �:'/d�PTrcN dFd t I �VVTTr/// 4r1 ,�". �� .�` i (\ I/Z IL d?U d t'(:7' .r„;..+:�. ; t-� ± �.'...U �r• � � ,ram f 4 . i nv E� 'XI f, i -: :l� dQ -v� }rY�Y 1 k t �' _,.f. "� 'a'Tf��?'� "ate' , +�, ,r�a��'S -c c t^,x,, t --• i r�—'^-+}'.:+�k^�' it all -� 1. + �� fi� � .t E��{. �..� .�. -��/�ac' `1 - .J t! •'r i r� �r f r +► ) _ .Q „* 1 d'Ap IN t 11 I 1 � � ;r ;\ �• E wry �.L.'.'sVJ �.Ct Qa,y jtr.,� I /��. t \`• I tl� �j CL)1.I'.1'i"'i"^►�i'��'tii ;'T�w i"r. i'..i::r ,,��r s�'j, y .��"7"� `"''r a+'� r 1�•T" `�� t�.>; r I,7 Ll �` �. �T L.•� � ,: J S 6.. ! t F/tYy ( iL � .Y t-E l ', r Mil.*�. - :! �:.• � ` ! �d ^m"'- .�� 't S ,viv WL\f.: J�.' t. .� a�� s,s�n s�ai {•fin,ltq��j r�."� W��"�/,��v,'�iac....�! _. � � - '-�:. w t .fit FIA� A'I V 4 1 � kz LAL rl J /t,y Mj QA »..r:1.e�.aC:i�r�.-�_p.�s.e�.+f4�a�.=;-..�.. ._ ..........�. _. -�,�?�.�l�:a.s.:.:::'..:.:� -�:r:-._. .:-xx.. -Yr r '-•f_ _ — _-�a+te�s ..iu.A':e�m-_.: r .. •�� •� (-/)p� � Y t � `h(�)n��.$/, A(ry q� .9 ldr^I' -��1 � wf V' rl�v� �� • +- �. ,. � - .. •I ff / ��il^VA 7.df;��4�S v Y�4 1. � �„6•,F �ye.. Inis 2/ cl focK(7 a 6' : ( y ,/!n t I �ac ; _ .. CA, tix i COMMONWEALTH OF MASSACHL'SETTS y EXECUTIVE OFFICEPF ENVIRONMENTAL AFFAIRS 12 ' DEPARTMENT OF ENVIRONMENTAL PROTE ONE INTER STREET. BOSTON. NIA 02108 61 7-292-5, WINTER i D wILU A��F.WELD 350 MAIN STREET Q,e�.� W -F Governor WEST YARMOUTH,MA !"` r an ARGEO PAUL CELLUCCI 508-775-2800 DAVID T UFIS Lt.Governor ` r ssioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM 9 CA PART A CERTIFICATION MAP 142-081 LOT 59 PROPERTY ADDRESS: 119 STONE�,HORSE ROAD,OSTERVILLE ADDRESS OF OWNER: DATE OF INSPECTION: AUGUST 27, 1998 SALLY SHUFFET NAME OF INSPECTOR: JAMES D.SEARS I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 9310 CMR 15.000) COMPANY NAME: A&B Canco MAILING ADDRESS: 350 Main Street,West Yarmouth,MA 02673 TELEPHONE NUMBER: (508)775-2800 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 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 CONDITIONALLY PASSES NEEDS FURTHER EVALUATION BY THE LOCAL APPROVING AUTHORITY FAILS INSPECTORS SIGNATURE: DATE: SEPTEMBER 8, 1998 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 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 as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: SITE OVER ALL PASSES, INSPECTION OF SYSTEM IS BASED ON CONDITION OF SYSTEM AT THE TIME OF THE INSPECTION.THERE IS NO GUARANTEE ON THE LIFE OF THE SYSTEM. B SYSTEM CONDITIONALLY PASSES: NIA 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 b the Board of Health,will pass. Indicate yes,no,or not determined(Y,N,or NO). 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 t unsound,shows substantial infiltration or exfiltration,or tank is 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. Page 1 of 10 (revised 04/25/97) DEP on the World Wide Web:hftp://www.magnet.state.ma.un/d SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTINUED) Property Address: 119 STONE HORSE ROAD,OSTERVILLE Owner: SHUFFET,SALLY Date of Inspection: SEPTEMBER 27,1998 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). 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: N/A 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 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 to 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 1 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 and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER (revised 04/25/97) Page 2 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 119 STONE HORSE ROAD,OSTERVILLE Owner: SHUFFET,SALLY Date of Inspection: AUGUST 27, 1998 D]SYSTEM FAILS: You must'indicate either"Yes"or"No"as to each of the following: N/A 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 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 over- loaded 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'/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 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 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 above: N/A 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 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 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 04/25/97) Page 3 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 119 STONE HORSE ROAD,OSTERVILLE Owner: SHUFFET,SALLY Date of Inspection: SEPTEMBER 27, 1998 Check if the following have been done: You must indicate either"Yes"or"No"as to each of the following: Yes No X Pumping information was provided by the owner,occupant,or Board of Health. X 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. N/A As built plans have been obtained and examined. Note if they are not available with N/A. 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. X The site was inspected for signs of breakout. X All system components,including the Soil Absorption System,have been located on the site. X The septic manholes were uncovered,opened,and the interior was inspected for condition of 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: X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Sub-Surface Disposal System. N/A Existing information. Ex.Plan at B.O.H. X Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable)[15.302(3)(b)] (revised 04/25/97) Page 4 of 10 f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 119 STONE HORSE ROAD,OSTERVILLE Owner: SHUFFET,SALLY Date of Inspection: SEPTEMBER 27,1998 FLOW CONDITIONS RESIDENTIAL: Design flow: 440 g.p.d./bedroom for S.A.S. Number of bedrooms: 4 Number of current residents: 1 Garbage grinder(yes or no): YES Laundry connected to system(yes or no): YES Seasonal use(yes or no) NO Water meter readings,if available(last two(2)year usage(gpd): 1997 26,000/1996 20,000 Sump Pump(yes or no): NO COMMERCIAL/INDUSTRIAL: 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:(yes or no) Water meter readings,if available: Last date of occupancy: OTHER:(Describe) Last date of occupancy: PRESENT GENERAL INFORMATION PUMPING RECORDS and source of information: N/A System pumped as part of inspection:(yes or no) YES If yes,volume pumped: 1,000 gallons Reason for pumping TYPE OF SYSTEM Septic tank/distribution box/soil absorption system X Cesspool X Overflow cesspool Privy Shared system (yes or no)(if yes, attach previous inspection records, if any) I/A Technology etc. Copy of up to date contract? Other APPROXIMATE AGE of all components,date installed(if known)and source of information: UNKNOWN Sewage odors detected when arriving at the site:(yes or no) NO (revised 04/25/97) Page 5 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 119 STONE HORSE ROAD,OSTERVILLE Owner: SHUFFET,SALLY Date of Inspection: SEPTEMBER 27, 1998 BUILDING SEWER: N/A (Locate on site plan) Depth below grade: Material of construction cast iron 40 PVC other(explain) Distance from private water supply well or suction line Diameter Comments:(condition of joints,venting,evidence of leakage,etc.) SEPTIC TANK:X (Locate on site plan) Depth below grade: Material of construction concrete _ metal _ Fiberglass Polyethylene _ other(explain) If tank is metal,list age Is age confirmed by Certificate of Compliance (Yes/No) Dimensions: Sludge depth: 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 dimensions were determined 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.) GREASE TRAP: N/A (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: (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 04/25/97) Page 6 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 119 STONE HORSE ROAD,OSTERVILLE Owner: SHUFFET,SALLY Date of Inspection: SEPTEMBER 27, 1998 TIGHT OR HOLDING TANK: N/A (Tank must be pumped prior to,or at time,of inspection) (Locate on site plan) Depth below grade: Material of construction concrete metal Fiberglass Polyethylene other(explain) Dimensions: Capacity: Design flow: gallons/day Alarm level: Alarm in working order _ Yes; No Date of previous pumping: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) DISTRIBUTION BOX: N/A (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc,) PUMP CHAMBER: N/A (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.) (revised 04/25/97) Page 7 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 119 STONE HORSE ROAD,OSTERVILLE Owner: SHUFFET,SALLY Date of Inspection: SEPTEMBER 27, 1998 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: Type: leaching pits,number: leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number, 1 alternative system: Name of Technology: Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) POOL#2 BLOCK DRY T DEEP COVER 14"BELOW GRADE,ONE LINE IN, NO TEE WALLS ARE CLEAN. CESSPOOLS: (locate on site plan) MAIN POOL#1 POOL#3 Number and configuration: 1 1 Depth-top of liquid to inlet invert: 3' 40" Depth of solids layer: 4" 6" Depth of scum layer: 0" 0" Dimensions of cesspool: 7'6" 7' Materials of construction: BLOCK BLOCK Indication of groundwater: NO NO 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.) MAIN POOL,ONE INLET ONE OUTLET, NO IN TEE,OUTLET TEE COVER 12"BELOW GRADE. POOL#3 KITCHEN AND LAUNDRY ONE INLET NO TEE,COVER 4'BELOW GRADE, NO HIGH WATER MARK. PRIVY: N/A (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.) (revised 04/25/97) Page 8 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 119 HORSE POND ROAD,OSTERVILLE Owner: SHUFFET,SALLY Date of Inspection: SEPTEMBER 27, 1998 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) w Flip 3� �s O o"' O �a ems' (revised 04/25/97) Page 9 of 10. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 119 STONE HORSE ROAD,OSTERVILLE Owner: SHUFFET,SALLY Date of Inspection: SEPTEMBER 27, 1998 Depth to no groundwater 12 feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained fro Design Plans on record X 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 Use USGS Data Describe in your own words how you established the High Groundwater Elevation.(Must be completed) NOTE: HAND DUG TEST HOLE TEST HOLE NOTED ON PAGE 9,TEST HOLE 3 1/2'BELOW BOTTOM OF POOL#2 (revised 04/25/97) Page 10 of 10