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Home My WebLink About0063 BRACKEN FERN ROAD - Health 63 BRACKEN FERN; w4 "" r A = 043 007 J {Q� !UWN Ur t5AKNJ1AbLt ,J E and( f,� VreAV�J QA , SEWAGE # I� VILLAGE" CTyoyc ASSESSOR'S MAP & LOT �2� INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY \(300 a4,\ LEACHING FACILITY: (type) e%\ (size) 1000 O 1 NO.OF BEDROOMS BUILDER OR OWNER PERMPTDATE: �`(o �� COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the� ^-@ 4 r mme-hing made.. $ t Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) N Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) ��l A Feet Furnished by_—�Atkr a Q a A .1 e / THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH q3 - 7 - tO ... ................OF.......09mo rb`c........------------......-----------------.......---•---- Appliratinn for Disposal Works Tunstrnrtion rrutit Application is hereby made for a Permit to Construct (A) or Repair ( ) an Individual Sewage Disposal System at: ....................................... •...----- •••----•---•-------•-•--••-----•-•----••-••-•---•. Location-Address or Lot No. en ea 1C..... 1►a► acr.tl...Jt`.Xra.... !r/.................................. Owner Address .................................................. Installer Address Type of Building Size Lot.... �,�.'¢�-$----Sq. feet 0-4 U Dwelling—No. of Bedrooms._... lY' .......................Expansion Attic ( ) Garbage Grinder WO) Other—T e of Building No. of persons............................ Showers — Cafeteria 04 Other fixtures ................................... W Design Flow................................S.S...__gallons per person per day. Total daily flow..........._._._......._.._.. • ....gallons. WSeptic Tank—Liquid capacity_1CQ_gallons Length__B i:l�a.`._._ Width.A.71Q...._ Diameter................ Depth.5.~$.... x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No....�¢ -------- Diameter.....tA.t...._..... Depth below inlet.....6t........... Total leaching area..-Zs.7_....sq. ft. Z Other Distribution box (% ) Dosing tank ( ) ~' Percolation Test Results Performed by_____________3_._5t�c�?lei.....•..............._...._..__... Date.... .�� a ,1-------------------- 1 Test Pit No. 1......2-_----_-minutes per inch Depth of Test Pit...... Depth to ground water... . .- ........ Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground w a' --••--......-••••-----------••......• ••••-•-•--•-•--••••-••••••••-••••------------------------•......................-- • �•-•---. - O Description of Soil......9--2. ..�.. �ol� . .oam- -•Svva �---------------------------------------------•-•••-•-• SIEPliFJ�l.:. ........................•--•-------... . ••..... YYI�Jtclll�im.. Y4Gf................-' ALLYN U WILSON W ••••-•---------------------------•-•-••-••--•-•-••••--•••--•--------------------•---•-••••••••••••••---••--••-••--------.....---...-••-••............. .... .9071; Z. U Nature of Repairs or Alterations—Answer when applicable----------------------------------------------------------- ` e t ----------------------------•--••----------•-----•----•--...-•-•--•-•-•-•---•-••---••--•--••-•----------•-----------•------.....----------------------------..--••••-•'' _ aA Agreement: - ' �MAC 6Z The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in cor ance with em/eo, the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the is•�' system in operation until a Certificate of Compliance has been issued by the board of health. Signed ........... . . ..............:...... ... . ------------- . o -- Application Approved By ........ . Date'-------- - /.1:'- .. .`�....... Application Disapproved for the following reasons: ....................................................... .. .. ........................................... ... ........... . . ............................................ ..... ... .. .. .................................... .. .. .... .... .. Permit No. .�° Y ``� Issued -------------- --------------------....---..._-.... Date...-- Mte i 1 ................... ... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH OF...... Appliration for Biiipniittl Works Toni5t•rnrtiun "prrnti# Application is hereby made for a Permit to Construct (A) or Repair ( ) an Individual Sewage Disposal System at: .4c� E!�l_ E2!✓ �.� /��i�0�97o�/S ��lc C�' 10 7-- ..................•-••-•••..•... .--- --------------- ... .................................................... Location-Address or Lot No. .i�:_:::f:2 .� ...._,��yky,� i + �/!_c�Zfn ---•-•...............••-........... .............. .•••... ......... �% ya Owner Address a .....4 /oI / J.W. / i!//ti7a � / a Installer Address /- Q Type of Building Size ...Sq. feet Dwelling—No. of Bedrooms___=.T a: ........................Expansion Attic (410) Garbage Grinder (4/6) '04 4 Other—T e of Building No. of persons............................ Showers — Cafeteria QI Other fixtures ............................ . W Design Flow.................................a 5.....gallons per person per day. Total daily flow_.__.___.....__....._.........-�..�®....gallons. WSeptic Tank—Liquid capacity.!_.gallons Length__ �' "�... Width_4 4b: .. Diameter................ Depths_�_�� x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....�s_...___sq. ft. Seepage Pit No.....s_?�c......... Diameter.....k�.......... Depth below inlet.._.._.......... Total leaching area..•---..•_.7....sq. ft. Z Other Distribution box (X) Dosing tank ( ) ~" Percolation Test Results Performed by.............:1____ .................................. Date..._:/ �..........._... aTest Pit No. 1------z-------minutes per inch Depth of Test Pit______l ....... Depth to ground water_____________ ________ Gi, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground _ _--.-_-__. Vk Ad. 04 •••-•---•-••----•---•••--•••--.....--•-•-•-••••--•------••...............................•••••........................ w 0 Description of Soil...... ... t�+�._...4_� m , -Sotosr,I I �. -_ U ............................................ . . -•-••• AIWAN....... - - -- -- -- - - W -----•-•••••••---------------------------•=•--•••-•••-•----•------- .....W I.S0•-_... `0 UNature of Repairs or Alterations—Answer when applicable..................................................... .�No_3----- Agreement: N ,_ The undersigned agrees to install the aforedescribed Individual Sewage Disposal Syste a ce with e.ra« the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the ie,Zo 87• system in operation until a Certificate of Compliance has been issued by the board of health. Signed ........ ------. --------------- --- ApplicationApproved BY 1 -- ........ --- ---------------------------j---------------------..----------------------------- �/ .. 7.....�.�------. Date Application Disapproved for the following reasons- .................................................------------------------------•--------------------...-------------------------------- ........ . ............ ............................................... --------------- .-- .--•-------------- ---.......------.-----.. -- .--................--- --- . Permit No. .-------- -�L--------------V------- ---- - ---------- Issued .....................................-...............-. - Date ........ Date THE COMMONWEALTH OF MASSACHUSETTS �-- BOARD OF HEALTH -----.,/"-`'°'.�-------------- OF .--...... , r/;S?" c. ---------------------------- Gertifirate of C�ompitttnce THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( `� ) or Repaired ( ) by--- '.9 1r r T.._... r -✓___S__'-7l - ............................................................ Installer at o .--��------ leC�/ .. /2. .....•& :: �. / iGG has been installed in accordance with the provisions of TITLE 5 f The State Environmental Code as described in the application for Disposal Works Construction Permit No. .....- Ct�..:..� -5�---..... dated ................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE----? -------9 ............ Inspect l,/I i.. �� THE COMMONWEALTH OF MASSACHUSETTS - BOARD OF HEALTH OF.- FEE. Rqui • 1 Works Tnntr i n rrntit Permission is reby granted-- .....�---••••---...............................t .....•....--......--•--............................ ......... to Construct ( or Repair ( ) an Individual Sewage Dispos System Y at .//.._0,-e CI<.�:'1l.... 4 '✓_...t�d3„ .�s. i�+ ....o ., .` •••--'- •---------------------------------------- Street as shown on the application or Dis osal Works Construction e it No. Zy':�t�� Dat .................... ..�_. O (�fi� ✓ -----------�.. DATE ..................•.. a of Healt FORM 1255 HOBBS & WARREN, INC., PUBLISHERS 11-3 G e--,ein/pE,e o tit) I-r?414•'C4o4u• //d x• 3 = .330 �.l�D. USE /cam �4L, 5, T.zk//c LoT" 0/ � fir u5� 6a I _ G_ /o s�:.A eJ s�pEGu�I.L 4ej!'=-4 = /7 0 5,11=" . ' T`, - —.BUY /3orr'o/y �,2�c1 /�y. z 7a7A- L� 7-��!4y r-Zocc-j a 330 d,. P.D. 114 f� �. rE - "/�/Z/�Jt-✓ 02 LESS l¢3 OF 7 STEPHEN /V l03 s5 ALLYN V- 6. /03 . a 10616 / sONAL TF�Sr•yo�.E P4t57&8 J. J�1cof3%-bye/nIEG� FG• 'Z.O _ svpS`x,i[. /O�p ��•� D/ST, /C.�'c7 IAIV :•..� /O Z�� G4L Lin/ /M/ BoX /•vim C5 -. : +� MEN, '• /r w Z T.v.vic' Sid,./� E /O/Z /D/y G'E.GT/F/ECG PG OT PL:QN �---c �- L /v142 ST'ar/ 2' z 2-c37- // Tf/,47-THE .d�S/1�fETI�/1GY_ .eEQV/PENI�NT.S d� Th'� B.dXTE.2 �t/YE /.tiC, TDWif/ aF fjs=�i2s�� 13(,Lt/JiVIJ /S VDT, i2EG/ST�"BcIJ.G4N0.S!/.ey�cYpP� L.00sfT,�.O C�S�.GYfLLc �- iyf,�s,� 11A Of ea�o 3 U o� To E•s l�G&. V Low N ya7-l�E Us p r TOWIpF BAR STABLE c LOCATION/g/ /i ��c,Ge , w RV SEWAGE # 91 -6 , �! VILLAGE �(A.� , ��•��1 ASSESSOR'S MAP & LOT n INSTALLER'S NAME & PHONE NO. 1 - 47 3 s' SEPTIC TANK CAPACITY LEACHING FACILITY:(type) �� (size) �,ovd NO. OF BEDROOMS P R PUBLIC WATER BUILDER OR OWNER Igm—p f: b>m,l% DATE PERMIT ISSUED: `'` DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No p. �Olo 6 Lt Y� �3 1 TOWN OF BARNSTABLE LC'AT"Y_' d N3 t � �� yA , SEWAGE # Vil-AGE k 1owe H�k S ASSESSOR'S MAP & LOT 10. INSTALLER'S NAME&PHONE NO. F SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) '\0 5A 1 NO.OF BEDROOMS BUILDER OR OWNER IC 1 N C PERMTTDATE: COMPLIANCE DATE: Separation Distance Between the: f Maximum Adjusted Groundwater Table to the�*^ ^f r��^^ ^ '�� 3® Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) N(A Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) NIA Feet Furnished by 316111 �.. .._, �� t 1 e � 3 � �1�-a�� _�i Pit-3i` 32-ab �3�3�', �3- 3s° COINEM0N EALTH OF NLkSSACHL;SETTS EhECL'TIVE OFFICE OF EN. �IRONl�IENTAI AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION _ ONE WINTER STREET. BOSTON %Lk 0210E (617) 292-5500 TRUDY CONE e Secretary ARGEO PAUL CELLUCCI DAVID B. STRUHS f Govern r Commissio.�er ' ow— O�J SUBSURFACE SEWAGE DISPOSAL RT A SYSTEM INSPECTION FORM Wr �•.1 ` ® CERTIFICATION Property Address: VQ.14Q�C i'AJ Name of Owner 1 tMi O dt eac js a1��(C Address of Owner: -'Au A g Date of Inspection: `�� 1'1►�va// Name of Inspector:(Please Print)H'Cyr ct t I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) ° y r Company Name: 4t-l'„ ? Ek t�;'t^��r.. r... Mailing Address: _(�Q�� 4 /—i tf-G Nr E-t /`YM Telephone Number: 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: F Passes _ Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority _ Fails Inspector's Signature* Date: — 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 t 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. f NOTES AND COMMENTS t c � . �Qr� - �;b St�f�►S a� a, s ' ��-S�`STvv►�tQln�� f REt�iVEO e - co A p R 5 1999 //�� .. �{/rMW � r s WAIaHDEn revised 9/2/98 Page Iof11 g- ` Printed on Recydcd Paper � i r, r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) >f "roperty Address: Jwner: Date of Inspection: INSPECTION SUMMARY: Check A, B, C, or D: e e A. SYSTEM PASSES: I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure criteria not evaluated are indicated below. COMMENTS: 5 l{%A OftsSeFi,, C-��-- O 5 Tv T LC —U O F J ffcy t PU B. SYSTEM CONDITIONALLY PASSES: One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Indicate ves, 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 (with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed I f • i i i i qF 4 1 revised 9/2/98 Page 2of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (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 a system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 0 CMR 15.303(1)(b)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND AFETY 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 alt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND P BLIC WATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC EALTH AND SAFETY AND THE ENVIRONMENT: _ The system has a septic tank and soil abso/Ption 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 abso system and the SAS is within a Zone 1 of a public water supply well. _ The system has a septic tank and soil abs system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil ab orption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a wel 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). 3) OTHER / 1 j i I i ]jI S i i i + E { revised 9/2/98 Page 3of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (contirwed) Property Address: Owner: Date of Inspection: e e D. SYSTEM FAILS: You must indicate either "Yes" or "No" to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR .3 33. The basis for this determination is identified-below. The Board of Health should be contacted to determine what will a necessary to correct the failure. Yes No Backup of sewage into facility or system component due to an overloaded or clogge SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters a to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overl aded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available volum is less than 112 day flow. Required pumping more than 4 times in the last year NOT due to cl gged or obstructed pipe(s). Number of times pumped_. Any portion of the Soil Absorption System, cesspool or privy s 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 a public well. Any portion of a cesspool or privy is within 50 f t of a private water supply well. Any portion of a cesspool or privy is less-tha 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the ll has been analyzed to be acceptable, attach copy of well water analysis for =coliform bacteria, volatile organic compo nds, ammonia nitrogen and nitrate nitrogen. E. LARGE SYSTEM FAILS: You must indicate either "Yes" or "No" to each of a following: The following criteria apply to large sys ms in addition to the criteria above: The system serves a facility with a esign flow of 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environ ent because one or more of the following conditions exist: Yes No the system is ithin 400 feet of a surface drinking water supply the syste is within 200 feet of a tributary to a surface drinking water supply the s tem is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA) or a mapped Zone II of a public wat r supply well) The owner or op er or of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Dep rtment for further information. I - f revised 9/2/98 Page 4orn i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: Ls Owner: Date of Inspection: e 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 beemreceiving rwrmal 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 NIA. XThe facility or dwelling was inspected for signs of sewage back-up. 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: XExisting 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) (15.302(3)(b)I The facility owner (and occupants,if differeru from owner) were provided with information on the propermaintenanre-0f SubSurface Disposal Systems. f f i } ) i 3 revised 9/2/98 Page 5ofII f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM, PART C 2p Qp�^ SYSTEM INFORMATION 'roperty Address: � 'at-)' Owner: Date of Inspection: FLOW CONDITIONS a e j RESIDENTIAL: Design flow: g.p.d./bedroom. Number of be rooms(design):__03 Number of bedrooms (actual):% ' Total DESIGN flow33o Number of current residents: Q�A - Garbage grinder(yes or no): 1-41 Laundry(separate system) l es or 0 If yes, separate inspection required Laundry system inspected 4 or no) Seasonal use (yes or no):-& Water meter readings, if available (last two year's usage (gpd): Sump Pump (yes or no): �J Last date of occupancy: "0\ COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow: qpd ( Based on 15.203) Basis of design flow Grease trsp 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: GENERAL INFORMATION PUMPING RECORDS nd sourc of'nformation: �� , j UVVI� dt Ce�DZ C. �tV Y i a System pumped as part of inspection: (yes or no)_ ) If yes, volume pumped: gallons Reason for pumping: TYOF SYSTEM Septic tank distribution box/soil absorption system Single cesspool I Overflow cesspool Privy i 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 r Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components, date installed(if known) and source of information: I Sewage odors detected when arriving at the site: (yes or no) i revised 9/2/96 Page 6ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 'roperty Address: Cob g Owner: Date of Inspection: BUILDING SEWER: )' (Locate on site plan) I . 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: 5 (locate on site plan) 6 Depth below grade: Material of construction: oncrete_metal _Fiberglass _Polyethylene_other(explain) If tank is metal, list age_\ Is.age confirmed by Certificate of Compliance_ (Yes/No) Dimensions: Sludge depth: 41`r it - Distance from top of sludge to bottom of outlet tee or baffle r Scum thickness: Distance from top of scum to top of outlet tee or baffle: y Distance from bottom of scum to bottom of outlet tee or baffle:_ How dime-isions were determined: ��2 comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth off liquid level in relation to outlet invert, tructu in grity, evide ce of leakage,etc.) GREASE TRAP: (locate on site plan) Depth below grade:_ Material cf 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.) 1 i e r revised 9/2/98 Page 7of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C ,p "� SYSTEM INFORMATION (continued) 'roperty Address:cp�j fjWz1( V_ Ytx_+ s. Owner: Date of Inspection: TIGHT OR HOLDING TANK: (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: gallons Design flow: gallons/day Alarm present 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:lilkS , (locate on site plan) ((�� Depth of liquid level above outlet invert: GJC 1 Comments: (note if level and disFFributio is eq al, evidence of solids carryover, evid of leakage into or out of box, etc.) - 'won l 4��t1Z��:�oo� 2o.V 1 I ,1 1 1 PUMP CHAMBER:_ ` (locate on site plan) I Pumps in working order: (Yes or No) i Alarms in working order (Yes or No) Comments: (note condition of pump chamber,.condition of pumps and appurtenances, etc.) ( revised 9/2/98 Page 8ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) `roperty Address:4e3 6a '—RN Owner: Date of Inspection: SOIL ABSORPTION SYSTEM(SAS): (locate on site plan, if possible; exca tion not required, location may be approximated by non-intrusive methods) If not located, explain: Type: leaching pits, number: �ix� leaching chambers, number:_ leaching galleries, number:_ leaching trenches, number, length: leaching fields, number, dimensions: overflow cesspool, number:_ Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, dam&soil,�ondi ' n of vegetatio , etc.) 1�t( o4 f k JA � ` v U CESSPOOLS:_ (locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: )epth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY:_ (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 9/2/,98 Page 9ofII 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) 'roperty.Address: b J � � mv—,V..0-3 )weer: Date 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) I 1 1 1 n I �� 1 v t i i a O I 43- 3S revised 9/2/98 Page 10of11 Y SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) toperty Address: Owner: Date of Inspection: NRCS Report name Soil Type_ 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 Groundwaterk (Feet Please ind;cate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record i i Observed Site (Abutting property, observation hole, basement sump etc.) Determined from local conditions Checked with local Board of health i Checked FEMA Maps Checked pumping records Checked local excavators, installers Used USGS Data Describe how you established( c the High Groundwater yElevation. (Must be completed) V 1 J► �`O C—a`�1 � �,��C/�D 0 revised 9/2/98 page llof11