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HomeMy WebLinkAbout0018 BRENDAS LANE - Health Bxendas Lane�18 Marstons Mills P d A = 028 063 I. �I I I I f 8 8 ^ )DIC COMMONWEALTH OF N ASSACHt'SETTS4EXECUTIVE OFFICE OF E?�VIRON. 1E\TAL!OFF S RfCfIVrDEPARTMEN'T OF E'sVIRONMEITAL PROT I0. 19gONE 'INTER STREET. BOSTON. NIA O'1U5 61? A 11'ILLIAVF W'ELD , -L0VI Govcmc. Se:tctarn ARGEO PAUL CELLUCCI DAVID B.STRUYLS Lt.Govemor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissions PART A CERTIFICATION Property Address: �ZI: l�*, \`�1�s,TcvS M,�\`a tAb. Address of Owner: ZL Date of Inspection: �O% (If different) Name of Inspector: -eceo ��d Cir`x1l,ttA2 tNS 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000)) Company Name:f}I ty y--,'c EA rr r,.,.1 N•r P.:Lk / Mailing Address: Rep Aoxt e 32!f H ASa/EeCL H -'} 0 2C,4-cl Telephone Number: CSO2t O CERTIFICATION STATEMENT I cert,fl that I have personally inspected the seviaee disposal system at this address and tha: the information reported belov, is true, accurate and complete as of the time of mspec:,o-.. The inspection Nas performed based on m training and experience ,n the proper iunct,on and mamsenance of on-site sewage disposa systems The s-sterr,: APasses _ Conc!t,onaii\ Passes Neec� Further Eva'uat, Local Approving Authorin, F . s Inspector's Signature Date: The S-stem Inspector shal' subm,: a cop- of this inspection reporl,to the Approving Authority within them- (30) days of completing this inspection. It the system is a shared systern o, ha; a design floes of 10,000 gpd or greater, the inspector and the system owner shall submit the repo-: to the appropriate regional office of the Department of Environmental Protection.. The orig:na! should be sent to the system owner and copies sent to the buve,, if applicable, and the approving authorit-. INSPECTION SUMMARY: Check A, B, C, or U A] 'SYSTEM PASSES: 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: 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 yes, no, or not determined (Y, N, or NDI. Describe basis of determination in all instances.. If,"not determined", explain why not. The septic tank is metal, uniess the owner or operator has provided the systems inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (201,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 conforming septic tank as approved by the Board of Health. (rsv:.&*d 04/25!97) Page 1 of 10 I DEP on the wond Wiae wet> hre rrwww magnet state ma.usmer °i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM v PART A -'� CERTIFICATION (continued) ' Property.Address: c3` Owner: ,/Date ofj,l'nspection:• CS,, y. B] SYSTEM CONDITIONALLY PASSES (contin.,-d _ Sewage backup or breakout or high static water level observed in the disc tbution box is due to broken or obstructed pipets) or due to a broken, settled or uneven distribution box. The syst will pass inspection if(with approval of the Board of Health). Describe observations: 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 t broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipetsi are replaced obstruction is removed C) FURTHER EVALUATION 15 REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board f Health in order to determine if the system is failing to protect the public health, safer`• and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETE INES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER ti WHICH WILL PROTECT THE PUBLIC HEALTH AND SAF AND THE ENVIRONMENT: Cesspool or prnti is within 50 feet of a surface ater Cesspool or priv\ is .%ithin 50 feet of a borde ng vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEAL H (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER T AT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a_septic tank and soil a orptton system (SAS) and the SAS is within 100 feet to a surface water supply or tributan, to a surface rater supply. The system has a septic tank and soil bsorption system and the SAS is within a Zone I of a public water supnty well. The system has a septic tank and soi absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and so 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 fro that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used t determine distance (approximation not valid). 3) OTHER (revised 04/25/97) Page 2 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Propertq ddress: is S Owner: i(_ Date of Inspection: if h following h v n done: You must indicate either "Yes" or 'No" as to each of the following: Check the have been 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 pan of this inspection As bull; plans !have been oo:a:ned and examined. Note if they are not available with N/A The fac:lin or d%%elling "as inspected fo, signs o*'sewage back-up. _ The systern does not receive non-sanitary or industrial waste flow. The site \,+as inspected for signs of breakout. All system co-nponents. excluding the So!: Absorption System, have been located on the site. •. _ The septic tank rn,anholes mere uncovered. opened. and the interior of the septic tank was inspected for condition of barfies or tees. materia; o'construction, dimensions, depth of liquid,_depth of sludge, depth of scum. —The size and location of the Sol! Absorption Svstem on the site has been determined based on- The fac,lit\ cwne• Lane occupants. if d,fterent trom owneri were provided with information on the proper maintenance of Sub-Surface Disposal Svstem. XExisting information. Ex Plan at B.O.H. _ Determined in the field !r am of the failure criteria related to Part C is at issue, approximation of distance is unacceptable 113.302.3; b (revised 04/25/57, Page 4 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) r Property Address: $(?bul-cl s Owner:br�_ Date of Inspection: D) SYSTEM FAILS: You must indicate ether "Yes" or "No' as to each of the following - I have determined that the s%,stem violates one or more of the following ilure criteria as defined to 310 CMR 15.303. The bases for this determination is identified below. The Board of Health should contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage into facility or system component du to an overloaded or clogged SAS or cesspool. Discharge or pondeng of effluent to the surface of the round or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the destribiition box above o tlet invert due to an overloaded or clogged SAS or cesspool. Leouid depth it cesspool is less than 6" below nvert or available volume is less than 112 day floe. Recuired pumping more than 4 times in the ast year NOT due to clogged or obstructed pipes:. ~umber of times pumped _. Any portion o'the Soil Absorption 5vst cesspool or privy is below the high groundwater eievatior, Am por;:or, of a cesspool or privy is ithrn 100 feet of a surface water suppIv or tributary to a surface water supple. Am po^.ion of a cesspoo' or privy s wither a Zone I of a public well. Any pc^io-. c-a cesspool or pri • is within 50 feet of a private water supply well Any por,,on o`a cesspool or rr\y is less than 100 feet but greater than 50 feet from a private water supply well with no acceotabie water qualm ana vsis. If the well has been analyzed to be acceptable, attach cope of well water analysis for coliform bacteria. volatile ganec compounds, ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: You must indicate ether "Yes' or "No" a to each of the following: The fohow;r,g crrer,a appiti to large systems in addition to the criteria above: The system serves a facility eth a design flow of 10,000 gpd or greater (Large System; and the system is a significant threat to public hea!th and safer a the environment because one or more of the following conditions exist: Yes No the system i within 400 feet of a surface drinking water supply the syste is within 200 feet of a tributary to a surface drinking water supply the syst m is located in a nitrogen sensitive area (Interim Wellhead Protection Area • IWPA) or a mapped Zone II of a publicwater 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 31, Cti1F 5.00 and 6.00 Fiease consult the Io-21 regiora! office of the Department for further information. (revised 04/25/97) pay• 3 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR..t PART C SYSTEM INFORMATION Q,, t Propert% Address: �S &� Owner: t Q% 2 Date of Inspection: I FLOW CONDITIONS RESIDENTIAL: Design iloi,% 30 a p.d!bedroom for S.q.S Number of bearooms Number o:current residents Q Garbage g•, der (yes or no,1 % - Laundry co—ected to system (,yes or no!U� Seasonal use (yes or no,. � . Water meter readings. if available (last two :21 year usage tgpd): 1�!'n Sump Pump (ves or no).__�,�) Las; date of occupanc-� COMMERCIAL'INDUSTRIAL: Type of establishmen: Design fio%% _Fallons,da\ Grease trap present (ves or no Industna! 1%aste Holding Tani; present ves or no_ 'ion-sanitan Haste dscnargec to the T!tie 5 sysem ;ves or no_ \later meter readings ii avallabie Las:Fa;e o; c -Panc. OTHER: .De:cribe Last care of occuoanc. GENERAL INFORMATION PUMPING RECORDS and urce of mformauor 4. System pumper as par of inspection: (ves or no. 'V If ves, volume pumped _ gallons Reason for purnping TYPE OF SYSTEM Septic tank/distribution box/soil absorption system Smgie cesspool Overflow cesspool Pri\,)- Shared system (yes or no) (if yes, attach previous inspection records, if any) I/A Technologv etc. Copy of up to date contract? Other APPROXIMATE AGE of all components, date installed (if known) and source of information: i (0 u e g Sewage odors detected when zrnvir:g at the site. ryes or not N(.! (revised 04/25/91) Dig• 5 of 10 SL,BSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: (Aj �.a0tAMI Owner: �� Date of Inspection:8r_ BUILDING SEWER: (Locate on site plan) Depth below grade. Material of construction: _cast iron _40 P�'C other (explain! Distance from private water supply well or suction li-t Diameter Comments: (condition of)oints, venting, evidence of leakage, etc.) SEPTIC TANK:deA (locate on site plan Depth below grade Material of construction: _concrete _meta _Fioerglass _Polvethvlene _othenexplain` If tank is metal" Iis: age _ I; age corfirmec d, Ce^:fica:e of Compnance _(les"No Dimensions ;)ZQQ!�tFY)i. Sludge depth Dtsiance from top o: siudee to bonorn o; outie: tee o, ba,";e Scum thickness ( �i Distance from top o'scum to top o; outle; tee or ba^ie 1O y Distance from bottom o scu-n to bo-o-n of outle: tee c, bane , l Z How dimensions were determined M1QSU&z-A Comments trecommendation for pumping�ronditiorn o, inie and outlet tees or braffl depth of liquid level in relation to outlet invert, st�cturalintegrity evidence leakage, t GREASE TRAP: (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 islet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.,- (revised 04/25,11) Page 6 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Properh Address: O%ner: (�¢� 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: Capacm: gallons Design flwA galions'da. Alarm level Alarrn In working order _ Yes: _ No Date of previous purnping Comments (condition o+• inlet tee. condator, o• alarm and float switches, etc.i DIS7RIBUTION BOX: K.s Jocr-,e on si:e p an 'f Dept:, o; Iiouid level. aoo.e ouue: in\e-. Comments incite .f leve" and disrib:::-or is ems• a' evidence of solids carryover, evidence of leakage into or out of box, etc.) w �ur%lcykjvo9 cc— PUMP CHAMBER: (locate on site plan. Pumps in working order: (Yes or No' Alarms in working order (1 es or No Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (reviaad 04/25/97) page 7 of 10 C f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1�3 4LS Owner: ltaasc, Date of Inspection: ok t 'n SOIL ABSORPTION SYSTEM (SAS):_S (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: L leaching pits. number. GX11. leaching chambers, number:` leaching galleries, number: leaching trenches. number,length: leaching fields, number, di pensions ovei4!ow cesspool, number Alternative system Name of Tecnroiog,. Comments. more condition of so I. s its o hvdrauUc failure, level of pond , cond�uon of v etpo c. CESSPOOLS: _ (locate on site plan Number and conftgura:,on Depth-top of liquid to inlet Inver, Depth of solids lave, Depth of scum layer. Dimensions of cesspool Materials of construction Indication of groundwate- inflow (cesspool must De pumpeC as par, 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 pondmg, condition of vegetation, etc.) (revised 04/25/97) page t of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: �,�tQj�ttlgS Owner: '42C, q._ Date of Inspenion: 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) teams • 2 d 3 (ravisad 04!25!5') Page 9 of 10 a SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Propertm Address: CS Owner: �nspetx�tDate of ctio Depth to Groundwater i30 Feet Please indicate all the methods used to determine Nigh Groundwater Elevation: Obtained irom Design Plans on record Observation o` Site (Abuning property, observation hole, basement sump etc.) Determine it from local conditions Check %%ith Iota' Board o• neaa^ Chec:. FE.MA Maps Check pumping records Check local excavators. rnstalle•s L se L SCS Data r• Describe to dour o�+- \%oros no•.+ \o., es:ab!!shed me ~ig^, Groundwater Elevation. (Must be completed U.S.1"e-r'1r✓gtc S24-v % tA.no\c,o)%C (o lzev:.sed 04,'25'9-. Paq• 10 of 10 -\ COMMONWEALTH OF MASSACHUSETTS 0 t EXECUTIVE OFFICE OF EIMRONME,�, AL AFFAIRS DEPARTMENT OF ENVIRONMENTAL, PROTECTION k J1 TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR.VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PARTA " ' CERTIFICATION Property Address: /$4t?h ju $ t7� Owner's Name: c e- 6.ps -:a-- Owner's Address: Date of Inspection: /-- /0 v I EEE . Name of Inspector: (please rint) TVA h 1q"jl` Company Name: �a�., a//� .ck c� SPrv� -r Mailing Address:. i£2 lfi /„ f ST •0&6-Yq «�ri Telephone Number: SU$- 4/2 -9S9S CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance oaf on site sewage disposal systems.I am a DEP approved system inspector pursuant to Section 15.340 of Title-5(310 CMR 15.000). The system: L/PasseS Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's.Signature: — Date: /-%-0 The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 'gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,ifapplicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title-5 Inspection Form 6/15/2000 page 1 f . Page 2 of l l OFFICIAL INSPECTION FORM-NCBT"IFOR'VOL-UNTARY ASSESSM�I'S; SUBSURFACE SEWAGE DISPOSAL SYSTEM INSP�gION FORM PART A CERTIFICATION(camtinuedi Property Address: /,g i 41h P Ar r ka s A//,' s . ." Owner: 8_ Ck,,s ; Q 4W ' Date of Inspection:_ f—/p a/ Inspection Summary: Check A,B,C,D or E/ALWAYS complete'aH oti! t 4�M ,y,►rf . A. System Passes: I have not found any information which indicates.that.any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"secjidq need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. . Answer yes,no or not determined(Y,N,ND)in the for the followingstatements.If"not determined" lease P explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank faihim is imminent System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of He4lth. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if:a rtificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break;oul or_high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box.System will pass inspection if(with approval of Board.of Health): broken piles)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 tunes a ear due'to broken or obs'rdtiedpipe(s).The s stem will Y 9 P P g Y Y pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS ! SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM PART CERTIFICATION;(continued) Property Address: /8 �riN �ss i�gat M" S 10a: /Y/," s i 4. Owner: Cr h Ki Date of Inspection: / — D/ C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass.unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment:. _ Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: ;j" V, _ 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 SAS and the SAS is within a Zone 1 of,iPpublic water supply. _ The system has a septic tank and SAS and the SAS ismithin 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well".Method.used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than.-5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: l} 3 Page 4 of 11 ` OFFICIAL INSPECTION FORM—NOT'FOR VOLUNTARY ASSESSMENTS ' SUBSURFACE SEWAGE DISPOSAL"SYSTEM:INSPEGTIONYORl PART.A - CERTIFICATION°(continued) r Property Address: /f 00-lhclG S ,,e ,/ r Owner:_�C 0, j(% ; e. Date of Inspection: l—lo-- o/ D. System Failure Criteria applicable to all systems:. You must indicate"yes"or"no"to each of the following for all inspections Yes No _✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool v 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 %: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 SAS,cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 1 of a public well. L- 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 fom a-private water supply well with no acceptable water quality analysis. [This system passes if b1ee4Q water analysis, performed at a DEP certified laboratory,for coliform bacteria and j dlptile organic compounds indicates that the well is free from pollutiop from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.1 Ala (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. + E. Large Systems: To be considered a large system the system must serve a facility with a design flow of.10,000 gpd to 15,000 ; gpd• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above yes no _ _ the system is within 400 feet of a surface drinking water supply _ _ the system is within 200 feet of a tributary to a surface drinking water supply, _ _ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well you If have answered" . Y yes to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large.system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. 4 Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPk6T' ION FORM PART B CHECKLIST Property Address: 4,.7e Owner: frorbc L. lyti,f� Date of Inspection. Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No _ Pumping information was provided by the owner,occupant,or Board of Health _ Were any of the system components pumped out in the previous two weeks? ✓ _ Has the system received normal flows in the previous two week period? c,Have large volumes of water been introduced to the system recently or as part of this inspection? ✓ _ Were as built plans of the system obtained and examined?(If they were iidt'available note as N/A) _ Was the facility or dwelling inspected for signs of sewage back up? r/ _ Was the site inspected for signs of break out? ✓ _ Were all system components,excluding the SAS,located on site? t/ _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? ✓ _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no V _ Existing information.For example,a plan at the Board of Health. Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)J 5 Page 6 of 11 OFFICIAL INSPECTION.FORM-NOT FOR'..OI:UNTARY ASSESSMEN S , SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM PART C SYSTEM_°.INFORMATION Property Address: 13,1-eA44I 14r• :'e gys�a �s-}li-is - Owner: Grps`!y Date of Inspection: !- /o- o`/ FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): '3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 3:30 Number of current residents: o Does residence have a garbage grinder(yes or no):Alo Is laundry on a separate sewage system(yes or no): AAo [if yes separate inspection required] Laundry system inspected(yes or no): A/e+ Seasonal use:(yes or no): A/u Water meter readings,if available(last 2 years usage(gpd)): N fJ Sump Pump(yes or no):.& , Last date of occupancy: i 2-90-20x70 COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gDd Basis of design flow(seats/persons/sgR,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no):_ Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): ' GENERAL INFORMATION Pumping Records Source of information: .f/v f,.,.., ykv*tik's Was system pumped as part of the inspection(yes or no): 46 ;1A If yes,volume pumped:_gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM i /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) _Innovative/Alternative technology.Attach'a copy of the cun=9 operation and maintenance contract(to be obtained from system owner) _Tight tank _Attach a copy of the DEP approval _Other(describe): Approximate age of all components,date installed(if known)and source of information: CLq�� /s'yrA�s Were sewage odors detected when arriving at the site(yes or no): Al 6 �; • Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS ' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: IS lie"s� � �^wtit vs cns ,�/s Owner: ,C,w ,to Date of Inspection: i— /U—U/ BUILDING SEWER(locate on site plan) Depth below grade: ;a Materials of construction:_cast iron 40 PVC_other(explain): ^+ Distance from private water supply well or suc n line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK:_(locate on site plan) Depth below grade: 12 .Material of construction: concret _metal_fiberglass_polyethylene _other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes dr"fro):_(attach a copy of certificate) Dimensions: 2000 194 Sludge depth: .3/' Distance from top f udge to bottom of outlet tee or baffle: 33'� Scum thickness: 2 Distance from top of scum to top of outlet tee or baffle: B Distance from bottom of scum to bottom of outlet tee or baffle: -2 How were dimensions determined: /Hc9fa)-iw r, syic-� Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of.leakage,etc.): 7�00 .a Tuh/c All A#Ak �'J' C'v4rs GREASE TRAP:_(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(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM—NOrT!OR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPEOTION FORM. PART C r SYSTEM INFORMATION(continued) Property Address: Is illti.t onS T1,77T Owner: C s , w { Date of Inspection: j— /O— ell TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(4atate on site plan) Depth below grade: Material of construction: concrete metal fiberglass___polyethylenp, other(explain): Dimensions: Capacity: Qallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no):. Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert:_a Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): il/o Sigh s o� Se1:� -'Csrry..Ov/✓ PUMP CHAMBER: (locate on site plan) Pumps in working order(yes or no): �'.,�►�r Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc:): 8 f. f Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: 8 Cvosbti. yr 1, l,Lh,'• c ., r Date of Inspection: SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation i14 equired) If SAS not located explain why:r:Y.04,17 J 's Y,,/�.W-1 r Ov? 2� FaSf Type I_ leaching pits,number:_ leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): A CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): � 9 Page 10 of 11 OFFICIAL INSPECTION FORM—NOT'FOR,VOLUNTAIZY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION continued , Property Address: f8 �y�N�a> L.4rJG P Owner: B,Gyos h � . w • e Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building. 29' 29 ' o r v S WL I ye��p 10 Y • Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS 'SUBSURFACE.SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: /$ Ay1 Owner: Date of Inspection: /— /o- e)/ SITE EXAM Slope , Surface water Check cellar Shallow wells Estimated depth to ground water 37 feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: (/Observed site(abutting property/observation hole within 150 feet of SAS) ✓Checked with local Board of Health-explain: Ayi .YH; Wol Checked with local excavators,installers-(aeGch documentation) t.-Accessed USGS database-explain: Ma oy a JpWn /-., ,t You must describe how you established thse high round water elevation: / d' fiQd h,' t> o's 3y lo. .ran 33 ��O fPHivti..f. C�ica E to d 11 f , ® r: CxisriuG cdc,� �,o,� >= I DI6,s-rr./S ����� PtrR ° Sew�r:ZGC�'rO �f 144 22 ,e: 1 )'I T I i 52FAc vAI LAF3�„� t05 1 I SY�.T R5 DA eW M,'r5TC-1(L V IYr � M 10 y / * 1-�' L oTir SOILICST 2 I O ..,�I( •!•% ' �� *n O AP""� (0 z s Z y Af o ALBE J p No.1U951�O ,y� 1o% w ID No 8 z ,Q.30•d' -_\ �/ 3 vtE`iL 51T}' Q� D r -15Q 10I , �A'S >EFIu1=a e�MAS?GR PLAW X ni47Lr L LQG4)+ou p7 6di5� L 1 40,p 1� 2 � {.IfJTE SEPTIC �`rST E M I y? �{Q BE RT ; y `�' 4, 5 foo S.F. o I I l0 150'FRo►jrAc� fC VJ>✓L1{.51-TES DEF'I►.�E=D " EL!?REDCiE 4 �v 3 . N �yA, No. 19387 �q 0t> 30' F5.r3 6`� MASTER RAr.! FILE °fC?sT=01%� A 1� 1*A �S" s u"73- O12+ cA-TaD MAY ISsLMBD PQ:3recTK:,"4LjNnc12. AAr•.� LEGEND �f� / EXISTING SPOT ELEVATION OxO ,A� CERTIFIED PLOT PLAN EXISTING CONTOUR --- 0 --- �� dF1 ti� FINISHED SPOT ELEVATION �� I I — G�>=►.1ea� 5 LAr.IE N a ' NISHED CONTOUR 0 � �+ `'� ��- iV1AQS'` 15 MIb-LS IN APPROVED , BOARD OF HEALTH` su DATE AGENT SCALE: - 4o DATE = LEVY & ELDREDGE ASSOCIATES, INC. CLSgNT4EP- I CERTIFY THAT THE PROPOSED ENGINEERS-LANDSCAPE ARCHITECTS JOB NO. �121-7 BUILDING' SHOWN ON THIS PLAN PLANNERS- LAND SURVEYORS � CONFORMS TO, THE ZONING LAWS i DR.®Y= J OF BARNSTABI L MAPS U 712 MAIN STREET CH. By: AAm a� � HYANNIS, MASS. I 2 .�r SHEET ,— OF DATE EG. LAND SURVEYOR PN 90(' - /»73 -4V d'_-3r_L tr/K ONl7 oziD _r bx,7lt;'f", �71NnOJ 0Nn01/9 ON �e�se► Z/L c35/nJdc �1VN015 •ONI 'S31di:DOSSV 3903da13 V AA31 TS60I-ON 6l 'oN \ t/ N On' 5-171 VY S�OLS�VY �, e 0nb5. � ,12i387V N!i • \ 18380ti f� Sy ��1 `jySsb11 kk � \Sy 10 1A, Z_W_.7 1,.Y N0I-LV700J13d }dIcn-d0��V3� _ Y� bS ��Z 1�3b�y� ON/NJtr'37 "7b101 r �GY'dol 1d 'tyS 1/c/21a7d 9N/NJb`37 WOL109 J' R11�a M044V7`O'.Va7cd v L-O ��i 9 ttivvd ,l8 U3Ss3,H-LIA4 s1'l'1753?! W Vol 1d 'ChS 1/d-b(3d 9N/H7t�.�'7 301S _cs*P1 "]ios -Z'o -3.t tad z•� X�7•�� Cicij ��73f I sl/d �nr//r���a"i �ro d�81�nN 0q#_LS.31 7/0.49' /0 -LS:.L 7/0S �tr'O�'7bJ pc� /Y1'07� 4.-71yW/.LS3 7b'101 007 7/0S o -Z'Wa �vsods�o���rsds �i v� :l d •d � NOrSN:�i-+�la � :s�vOom�r3�pro a+3dlKrnN /ro/s)r-YJv'lo ro N$/ �-7�s.Ts t�il�l�'L/2�7 N�/��a' /d/©/�.�✓']/rE�..L d'8/�L3�' �'�' ®.'�/I✓90tf$'fa75' 1'/ '6 1/o/ nJi1r/tYJts37 1�7IY/ - � ' /, Xc�nrolln®iarlsl�l�rino . - c7 Od(� �0 NO/1,735 1 - 6/ XU8 Nv/d176t/�1�141�'i'IY/. Q -- 34T3/� Yd 9.'obf- 3tN✓1 -- legs.L_-77.4n0 {�---. v d.� ld O 'Jo/ �N/tY7/!lam 1V L}eJi(N/ a d �G G� - S Z YL S. F •= :•� • O O/ 14 • • • • • I 1 O +' ¢i'x`„ — :gyp,r $ • i / �i1/.1J3 af3• • i a. aq Z lF • m .a 1 r . . . . • • 0 1S/a >iNt4 J/1d3S �NQLS 03Hs NM o°� a 1 • • . • • o p a '7d9 pp f/71/d _ o .7cflrf HOW. 7.9i137 c71n617 ONV5- /V t'S 7J m/�il O �06 V �t b�nf�/�/b Q iv/�IOJ o vol -�� -7-7VAIS W--7,40:J NO.Y/ _L5✓J AAtl'SF/ H011d 'N/W �1.7�JN0� .Td/d .7A&,6 � •✓�►riO.� �'�.��.7No� �ts�'.L:3'Wt//dam-b2 d`�v�a��, nriw Nbo'H-Z s7&O4V �blb' 1!d 'DA1.1J'•/_-)N37 . _ .. .: - � ,. s T .. lz� t•�jF�,, .' P _ :::°'.)e'{�`--qt 1:.b..". ° r Fi '. ; ,. .. f a ;'.ems-, `y » f' Syr, � '�" n): b,€�r 3 't#I�_ `�k %� y ,� '�b' �r YA�``r h ,� '4 ♦ 'r� v .e, r.:,r ... CQiViN10NfWEALTH OF MASSACHUSTTS a ; �/i g 4 k° S t r :xr ¢f ,s:' 0 FICE F E a^ P �9 NRC? MFNTAL FAIRS ;, Q'FVQ 4 Y 1'` T a �t - y '�, tT1Y` {,l+�:`M `-i+;.'C t Vt .f S'1•f b �..aM.f« ?k^6�M6R Y'I� sa Ld {wwtN M.r✓'+'Y'M }. 1� ' tit, DEPARTMENT'OF°ENVIRONMEM --PROTECTION ,,, a � .ir, s'w#' �"+�' f �.u^e v �h'2'¢r ,s a.f s�+�h,N��; "rK•F� x y^r y+� r`.^4.� iC t: � >'� r::y "`� �. �iys }r r A�3, O .'t4 k{r'�W'o.'#4 'F a k .� ai:"6 t< oyx,��. K .< ' �.' .'aX�fT •.-r 3 + '� { yfi,iFc`#-p.�r.T;, w,ss".€ �., r'=r"t + , 1 "' r• ">:4' ,,` f°i d.1 '�'r4' 'at.i'% .. r w -.'«';" i - :�y "rry..r���� `i"�,Y`` w`�T m ��a+'4.s-:•a<�,i�#'a.,. t~r 1' �.wk"`t �'�> 1 '.ww",.�"wre+W�`+n.'sr'�....� ::.�ww�+ti s*rew•:w";�,4. rb' �7 ".J'a»t �.b`t.. ,a c�'S. ±(gip �i ..�� �`'�`�G�i.t �e►'�� sY Y7 v�-`F`'f j - sr` ff°+ r�-`''oz_�'R y �,,r" ° d ,+ 3 �� � , , , � w . . •TITLE 5 XOFFICIAI:' 1i.a,/ .. °7:+ *•s r; ,e:,. etINSPECT ION;aFO, M .N,,.,OT.F. O. R VO L UNTAR Y.A.. -S SESSMENTS- ,� t. SUBSURFACE SEWAG9DISPOSAL SYSTEM FORM PT'A , r• y t r },• CERTIFICATION t,1 t,�• ) fxm' yy€`9q� ,ct''' '¢,Fr�+v3Y ri*47 ,.wi Yq+w �' £ ". 7£d• t. t r x.tib 1.. ,:.. i _..,, e z fi 4C� a ni a t t `35 d b:RfrreS� der dt r •` "` a K t. Kr> /r�'`� `33` Y, r �.` v A f :,.�/157,�' lE"4 - " Property.Address. �0 ��'�„� 5 �N ,t r wngr's;Name• .�,y.-►'" or , ft 4 . . d...rfa r.'. .-.. .,..a _ ,::" .l;,a5w'i •.,.w.w -.., y #� 3 Owners Address �+ t>'t-.�,�"��l^`9 Tvb- '�Yy� .t ^upr.�-'naws��t!/_/ '�'w%`'JA .�-a.1��-' ?G�r�-w�^«•ea�.,,.». ;.>r'.. •.r,.s..� ..a- �� � --. ° t �''Date of Inspection "` —;2 O q-/_ " x r� 'T a4 /� bt ; �� Namo of Inspector (please print) '~S��,n'' C. �}ti O T a 4 p y; T /t� fl.,s�rt�C✓l,'o1-) �., �wN QF 8 R �. rtCom an Name , , u { r#Y'�'� ;r✓ 't+F'` .�1 r�r /s A Q� >�%-U,`,Telepr�h�one Number' co n ieF kL7n 5, s: C'fl i. „T€ r�A:'t ,fix <wsa rra..t,�'g - .l".' .. i i•;L` 1x n4 °���'r,X' .,`. '�71^+.47 � j'!,�Y,'r�,,`t t�a 1 'r��.�'.S7 d�K?'E''•.^�y� tv J�Si'r:�?.� yz �..i, r+r rFh ` rt�`.)�v�;`.3+7 7 .x•Y-?fit' :J t ,..Zd' 1 �i.. .. #' , ` CERTIFICATION STATEMENT 3 '• �I certify that I have personally inspected the sewage disposal system at this address and that the information reported 1 s � below ts�true ryacurute andacomplete aswof the tune of the inspectton 4The uispection was performed based on my t x+ 8 t .,y„ ..< .. � ,qjr u -and experience�in the proper function and maintenance,, { _ , y„ 5 gf4onrsite sewage disposal systems I,ama DEP a r. ^-.wApproved system inspector,pursuantto,, action 15 3,40,of Title 5(310 CMR 15 000),u g,The system: r ,�r<;h,b t�_ _ 1 � � :1'�" -�' c%#'"S :a'�.r`�w1'f=r�.67 ` }:.�`'."' n;k6,°`e +4s•�Farb^'��r &k�$a •s.kn3N zf. 1"I`S!:ga"l;i,ri` .:r�`ia.n�; �'a '4tai:w7 t#y''�ti+`° e:-.1�6. - X v._ s , et'ass e$a :7.i., r rr it � � r -� Itt. t Conditionally Passes " `'. ` Needs Further Evaluation by the Local Approving Authority ' � ' �m Fails ..�f+Ewat s is ry f y Tz�.flw r m` � tI ii nsp' � .�.e4: kls #�'� �' r Iectorh,,Signature:�k70 f j b "�� rgti u. �.,fi'.+�aw r .�;r s .,+� s�- AsCtS ,(s<< + -7 Y tL, ♦f../� .,,'"s,. �.: y t.a�.y . �..�`ry �� ��>����x.. ��rc_pM^v � .u%'�� �.� fl..`�' :1" a 2r-...; { ' �ll.� d > �.�I.f�tt�},��j:}S� 1tN.Y •154;1y{3,,: � �' ¢ .The system inspector shall ubmit a copy of this aspection report to the'Appro;ing Authority(Board of Health or~, ; , � .w�, i'DEP)within 30 days of completing this inspection.If the system ts`a'shared'system.or.has adesign flow of 10,000 '� - r i , 1 � gpd or greater,the inspector and the system owner shall,submit the report.to the appropriate.regional office of the DEP The:original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving '. authority, ' k' } _ - Notes and-Comments4'41" >Irm�n i €� c�s 7=r�it ,fit.<�° -a WA .,,rr� ,� fW h. aT`sd ir, F .'.�sDf � '„�t `Fpr{, 4 as 3:Rri!h f. ii. 49 } y.R5TR 74�'H` ia > `94�.}' r1{ ',g ! ,xy.Tk A 4 t Y l.'c 'f 5.'��'j,,�*1akh� - r�� �t yv'y v�y c.k ,.g y S{y� �w�,�W;u��p'�'✓M.e�7tr tit`��11�,in,���� '+7'��. �,. ' x ' fr srs'• 're ^-:aw"'N1 ',§�'Sy�'t •, r.. s... ;:rtc,. "'. �„°� d .'::&�" "'s .,. o v°:,�•£,'P:,.'F#1��•;:'.'.!`J � + *This reporf`only describes conditions at the time of inspection and under the conditions of use at that ' time.This;inspection does not address how the system will perform in the future under the same or different � rOw �conditions of use., 0rq"�.'+R1.t't� �, `r3ayTt - {�<, Title S Inspection Form 6/1S/2000 a page 1 Page 2 of 11 a E' n :,7� a a art J4 11F OFFICIAL INSPECTION'FORM` N6ttORVOI;UNTARY-ASSESSM S y SUBSURFAC ;SEWAGE DISPOSAL SYSTEM INSPECTION FORM .. e ` . PART.A F CERTIFICATION(continued) " Property Address: ��r.►�4'S Lv, t > Owner ' -Date of Inspection:' • a-.]O-o-1 ,.,♦ Inspection Summary.`•Ctieck A,B,C,D or E I ALWAYS complete`aH of Sed1om D A. System Passes: I have not found any information which indicatei.that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304'exist.Any failure criteria not evaluated are indicated below , Comments: a. 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. ' ;.Answer yes,no or not determined(Y,N,ND)in the for the following statements If#`not�determinedi'please explain ! M� .�;(1 t.�'�rd� ",.. ,a r. .'S� ,Se:S .�''!,Y +�s�.� .}Y,j Mkt Jb ,-. i - +r� ',ti a 4 •E :x: �- ♦X t `2-The septic tank-is metal and over 20 years old*"or the septic tank(whether-metal oenot)is structurally unsourid,'eAibits substantial infiltration or exfiltraiion'or tank.failure is:imminent.System will pass inspection if the 1 existing tank is replaced with a complying septic taiilt"as approved by the Board of Health: *A'metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance.. indicating that the tank is less than 20 years old is available. irY4sS�: :ijli NDexplain. '' _Observation of sewage backup or breakout or high static water level in the distribution box due to broken or obstructed pipes)or due to a broken;settled or uneven -sirtbutionbox.System'will past inspuYion if(with. approvpa,l of Board of Heealth) 4 }gyp{ broken pipe(s),= .?.;"Y + . (d �} '.. .a i. ., .,•.. .. .'i ' obstruction ,distribution box is leveled or replaced ,. �. h 2+! }. .., ,.z !;- t ... ,: -...:. ,kP ..;. � ,.s.r:'.tire.,Y» !..,_.• .,'.... _it4 ♦ ,. ,>e? ND explain: The system required pumping more theft 4 nines a year due�d 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 Z:W .s..k` 3.4' ;,)n 45w29 rf aw4 47jie,•tin. .5:.t::<F�., J.{�<: -�, 4 iis•f Px.0 ash.'.;13! ... ...,.. t fy� +. ,.. , ..P - ,! ..:.5. .ND explaui: ! { Page 3 of 11 , OFFICIAL;INSPEC 'ION FORM:NOT7FOR VOIUNT.ARY ASSESSMENTS W � y,yfSkjJggURF,A,CE SEWAGE DISPOSAL SYSTEM INSPECTIONFORM: `{tMky 1 t p # �3 `�r^-A.,3vk #••s+r:1st &» I a s Ar. -,�PL11\Taii. j ;, yam k 's" •<F 4 �.• _ 4eCERTIFICAI'IONt(continued) �.t Q6� Property Address. v. Rtr A /vI/+/f A. OY� `/O �� 5.j.&fi �i. -•4 Ftt xk ♦, _ 4 / OWner O,, Oswe a/► 9 LDYIs.�N f-' ��i{/�1• / 4�`x' .yy�,� ��^ ` .if1 t � `J ,Date of Inspections' _,2 0=04-/ �C Further Evaluation is Required by the Board of Health: r..� a.r .1".`'a•n.. ' _ 'r%5 ,�£ta"„1`�G+y+y.i.i. +# a{ '�:! .s i fi' iS!:.,�•''�` .'� 1°1-. VI. _ Conditions exist which require further,evaluation by the Board of Health in order to.determine if the system ',' ' 4 "'ts failing to'protect public health,safety or the environment. J., F S# 1 "System wIll:pass unless.Boaid of Health determines in accordance'with.310•CMR•15.303 1 b that the p�r ty,'-: system is not functioning in a manner which will protect public health;safety and.the'environment:. F - ; � �� ��p >'"; i'^ •i' :. y ' , r `... t<1411#t F'� 5�,. �1•� � t#fit} ;; • a:Cesspool or privy is.withm 50-feet of.a surface water ° ! sk,,,s a�±',_ „ �.4.kF�1 Ala+t ii i t a <` , =rv4 } ` t yCesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh ?r.� :,t.•a + °�{. .5S!!a.(.t�` �'k���s�•m�if#d«� °�j+s f;�.¢�+f•:3,• i is�Sr.,�Ski-f!+!r i°g�:}t ��!t i� a., i" ii` �� t,. R ��#`,+ra#'lt� 4�r�^'!!�3�'�':�7r d�ti ,ca�!„�•+• �+..�$ -t �:t z � " ;�. ,. _w,. . .i'``i ,��; ,: 3r.,.. '� - .. p' I ey, tV{6! .t•w al 4Yk l €. A{ _I ? f H ` q �- �;`��• �3" L '°t ♦ �: '•�{a�}..p{'1I•+�,is,g�Sd't�'�:'{,+n''Egiz*r s�a.tw aa.'«,t9.�C.1 a°v��-:"s�rC��'•n4$��b Ott;�.f ='xLxip 6��i�y�YYr�'�,::.'a�..•'�a a USX.;`t,aj " „N:, , ___.. 2.:,= System will fail unless the Board of Health(and Public Water Supplier,if any)d.etermines'that the ;system is functioning in a manner that pro safety and environmentt tects the public health, _.•�� a#. 4jT2!'Ihe system•has aseptic tank and soifabsorption.system(SAS)and the.SASIS withutil00,feet ofa , , lsurface water.suppIy'or tributary to,a surface water supply ,r !a,tv� �a10;.L�,Gtl��xs 3 's�°�k` *s'I4-3e_F`°q'I'* rj.rat' f„ „3} • . Y ai The system has aseptic tank and SAS;and the SAS is:y!ithin'a_Zone'1 of apublic water supply. bwe 47 '� `lt3st . system has a septic.-tank and SAS.and the.SAS u,withiw50.feet of,a private water supply well. S' d cThe system has a septic tank and SAS:and the SAS is less than 100 feet but SO feet or more from a s. `r t yn ;private water:supply well.*.,Method used to"determine'distance .:E.... s.•` ;�. ;flfii, 31 y" `aa�s!•�.i" --kK.r.'#..53 t�1�f:{:a. S.>yt uY t xk. - This system passes if the well water analysis,performed at a DEP certified laboratory-for coliform r4�bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and >,, =:a the presence of.ammonia nitrogen,and nitrate nitrogen is equal to or less than 5 ppm,provided that no other.a „x failur6 criteria are.-triggere&A copy of the,analysis•must be attached to this form:? ��ail,#���a��x,,z��,,.a J:,f Yr ��Cr �-s- t o i t''�X,"•t�Y{"�C��],1 i 9d °+i-s� ,: y�.?zs 2� .gtfj S�n'� < t ram' r rt �.,°'+-.• #.,.,4- 3 r„,.` �! "f +r.: �8r.1�it� .{A,w�.r ?-`.°�,t G�E�S..titix�', ..4�?,• y .{,':ECT .3.F-'�3:?�,�rt+,5'f,Y.a... {aiF�, _sis° ,,;J;J' 'L �k�a � C•• w sue:: �w; t.>+v Y'c*., ' - - # 3 Other. , •., A `�'. f, J +•1sa.: '• .f #•s-•K y� ° ra �'"# ; z�, -y,';i r ,fl ar ��r;:,•i , , . - r '� 'w,:Y(:h Y. +'�?.t'.x tia ri ,w`�.r,tv. re J f• ! ..ti ;.{:.a;o !' } sy �Y � �. a t r.�•�I a a.�Si�'�S u{•'•F e b + , �tl � �Yr 1 !� ;:at 7 rF' � ..6 F •itf ",.`^;�.r.•,++j,"t`CT "�f-.g!r +•'ta.'#(t zrfSxr-3,,�N�•y.ja4yJr'��4."yy.pis' �("r.++-,'a w -,,t.t ay(g,�x:,{�°r.sk»",t i1+<•ya=p�,,4s,�ys.a,�,�rt3'-• rF� ,� •"� pl i } a._.M, f.-.. „- �"W ! ri a�°ts. i• ''w2 a �' 1 dh .i,.+�+,yy�i'y!�{q.,: i!�a (1••i j, ,} •y'A {`f�y J,,h {. t i . ,��-;�,�j t.ii � ,.9,,'i•t.({ ( � fit j Y..•C• '4,'i1m. R..{,KitlTx"kd_�? ?'�LA't6.:GlNE[i;F(+. ¢r$R'i�a34 4B !{'„ R E Po' F'4Ylf�, ,tyA' Ay hk�.:°.Tat1s'13.=haa.•i s'`�4 °" r R4 .h,i �':},y:4,rjtgq,7 "��° :�-',':rd1 zr �7tC�z�t.�� .„sty� f ,y _ ,f M. G .k,,S �• .is _ a'.> +t - i�e �'xc..�ffY'°i` k5CS�3£ '3ff't;,• i3•_ e;:G''- srjzj i(��. 'M -:'r 5 _ .t ,#x• t,x Sy t j.. vt° 1 W. 3 , Page 4 of 11 „ OFFICIAL,'IN$PECTION FORM"NOT,FOR•YOLUNTARY ASSESSMENTS •h SUBSURPAC_E"SEW— AGE;D,ISP-,OSAL SYSTEM 1�t;FORlV `.t rnr ,..y� i k -.w,, ra w".rKrh "' +�� a C,'r"°k.J•1 tl rc C`II�T X' 3 h N CERTIFdCATIdN.{coa>tmned) .a, r. tl *. Property Address" �� �ir�►�W �S Lv: ',,.r ; f= "`^ ^ l� }�;'I. Y /'Ilrrf/yrN S /YI�/ •� . �"r ^F.3 i. °,,.�.'a`..e. A.31.•,.!.r ...t�`..K.:..._.3.i f ._., . • Date of Inspection• aD saFt t'..' t dfi lc..s,...'•,p;.3..ay P: . D..., System Failure Criteria applicable to all systems: . , ''You must indicate:"yes"or"nk"to each.of the.following for,alf 0 ar'l,'ti P,',4 P, �1A;t !T.�'i5 '.�..;'t.�1�'"z,rs s 'd�. J .! ,. F Yes d; No a Yyy��t >• � e $ackup of sewage into facility or,systetri;:component;duF to overloaded or;.clogged,SAS,or cesspool :<�i~^$Discharge or:ponding,of effluent to,thcturface of the ground.or surface waters"due to an overloaded.or clogged SAS or cesspool L%,!Static liquid level in the distribution box above outlevinvert due to an overloaded or':clogged SAS or rt tt aa �Sr31 v4to wT. cesspool �n i��'f;.4 I.i utd depth'�•.. q.' p in cesspool is less than'V,below invert,or available volume is less than'/:day flow _r Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped d Any portion of the SAS,cesspool or pnvyis below high ground water elevation. ✓.Any portion of cesspool or privy. within 100 feet,of a surface water supply or tributary to a surface i $ri3 _s i 4 y d _wat ersupply:T tt �n . ni'i43t34"t,t LAC }sK41i' ..>T�s ki.J r�, .,prx:s.!°w it: #r`.9 b"�:� c_l I •�*J°Is. r ;Y , Any portion of a cesspool or,privy,is within aZone 1 of a public well ti.,, Any portion of a cesspool or privy is within 50'feet of a private water supply.well. ✓r:tAny.portion`of a cesspool or privy is ess han F 1.00;feet but I reater."50't6et7romi-private water supply well with no acceptable water quality,•analysis.-[This system passes,if the,�ell-avater•,analysis, k 'performed at a DEP.certified laboratory,for coliform bacteria and volatile organic compounds JVf'N'4"� 7 ',yp M+FS vi - . �dndIcates:that thewell Is free:from pollution from that,facility:and the.presence of ammonia ,r r nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other farisim criteria � a}. are triggered A copy of,the analysis must be attached;to this form.i t; iwnt z r�k ° /{�0 (Yes/No)tThe system fails:I have determmed.that one.,or,more of.the above,failuce.criteria exist as described in 310 CMR 15.303,therefore the system,fails .The system owner should contact,the,Board of f` Health to determine what will be necessary to correct the failure. �3' s . g ' t. ro ..`.fie . r .r3 t'� - b }r Z 1 fi ro .i•f! 3 K's. r ' . i -.�ri'�}•��J= ikr5�,�.$'.Gi:�a ?:n-."..t;�,y�ia.�:J✓i . .x rt:..,E,,.,.s ,'i i 13;°$ri 3 �,�{; °..' C 7Y,'::t. �' 1, ? ;..: °,..F� ,,..<s t.. ? L, Large Systems. x .>:s ar �n a. €; t .�.!,;=�i, °iy jL, fi •,t > ,x #, ...5 1.:: at 1a>, ,.'.t. ; ,. . . . . '< To be considered a large system the system must serve a facility with a design slow of 10,000 gpd to 15,000 gp( 5 r �a ,You must indicate either or"no".to each of th4 following: t "rt a following criteria apply to large systems m addition to the criteria above) �' �yks°y.' ''r'�tl*di 4'a'«- � 4 7 h` , ,.Si'd'a•�"Sr .yp x r «;,, .- r.' _ ,. • 1 R 1 yes` ' r `the system is within 400 feet of a surface drinking water supply, T .� .the system is within 200 feet of a tributary to a surface drinking water supply •.,_ ' "•t"� ' `14 `'the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped t:Zone II of a public water supply well''z` 12 t If you have answered"yes"to any question to Section E the system isconsidered a significant threat,or answered r x "yes"in:Sectton µD above the large system has failed.The owner or.operator of any large system'considered a ,} F. significant threat•under Section E or failed under Section D'shall upgrade the system in accordance with 310 CMR . I5 304 The system owner should contact the appropriate regional office of the Department. J tl {�:3%i t~ir ,,• r `sa¢ +q:,r ., w.. ' wt" 4. y x r Page S of 1 �',✓�F+'P��rrfx ✓• �s�� � b t :'? ft v r av tiv }( t - kelv% •.,'° `� *3°rr. y. M rk� •�y.h ".rt ar•/w!1,b:,y..,r�r r:c� s ✓,aSt �+ �7 a" - c t j a E'er OF I�:r � '�S�-i,,.a•f+r+ r :r.a ,rr«<�r�t- k�MYsR+'rcRtF.b�'-c z' �c"Y" -^• ... t,yt F IA.L INSPECTION FORM NOT FOR VOLUNTARY�ASSESSIYIENTS ? 5 A1G'a'q' ,t i 1 '.Y�••" d -k.k i y s _ *t $UBSURFACE"SEWAGE DISPOSAL SYSTEM INSPECTION'FORM ,.,r � kxk3 r�a�':1.f r�.a � f3. #�r.}✓i -L ;tL t PSf��Ty� .. .. ` r4+y r 'L"+ I�^� �`i 'syt'� <4r�',. ,.e"• x £s ra� ..� arir lA1,L/` a. �`.w.,z -. .� t' rr t ''� e� y f,W,t "i..7,-.•r �at� a �'�". s'�a y � - s > esuua`CHECKLISf� 3 /a .. ,1 ca--ark d y r ' Pioperty�Address /� �YP�'�4`Sf-WNP '`•• t,$: c i$Y y,a` {r, CrZ d"y* rs ynk�,..S j ..t�rTy„ � ✓'t"' t4 xa ��J ��J tl rr ni z "F y n, �G✓fr7Hl /0"M5 ,'4,M L v4 t x Date of Inspectlon, f' a ��; . t .`-y��.{ �c.h-a'°rw s „<s -,s, s p;, t�-• �{ri�I l#' {.�9L4}F t �P-s S i,f�. - � ns, x, +Check if the following have been done.You must indicate'"yes"'or`"no"'asto each of the"following:-'$ .y 33fi r � te`i��wf#�. i..�4*$r'xi !i r t<„�7 a+: jI f � * �}rY�• �i' � { '�«-'i� art:.1 �k .. }Ye JNo,4x, .f✓`s w �. {F s Ygt,zt ?g 3 '�R t' •s..-.ter: t('.1�`1L f.T. 3 `{�}n� til'"�*.� i,F }•..�,}f 5.as vi«)S .� 3sn:... r j # E Pumping iiformation`was p ovidedrb-0y the ownei;occupant;;or Board of Health p xa t.z�tk f -•, ,r� f r ..}.�., r.t�K t a ! s,'�� 'u� fi.`". . . �:✓`Wgre any of the system components pumped out inthe previous two..weeks? ,. �:.s t i„- ° U w `-"' .h. :R..,...».:.+�r�..-tee:a•.+�.e• ki ,c ��F��Sti�.'��.'�'ol.l..j =f4 Ma.'. the system received normal flows in the previous two v✓eek period.? ✓Have large volumes of water been introduced to the system recently or as part of this,inspection? s w tt 44 ;Weret.as built^plans of the system obtained and examined?(If they were not available note"as N/A) r_>..J.r t r �.3f '3_:,r• z K,�'^t'S`x,yl, •�•"'' � '., +,.,, .. ..�: .. `Y V a..-.o;s- ac r 1Was the facility or,dwelling inspected for signs of sewage backup? Was the site inspected for signs of break out �'� 4 r•r _t��, '�'#. +'° Y t,.'t ; d T �,r 4,6Y 'Y ��f',�.k r+.( t S�i Y.��-t t a'Y�i k f c C:? ft.t.�$ � ie.`��',^/{.�-> ar.' �{ ✓tWere all system components;excluding the,SAS,located on site- �r } / '. Were the septic tank manholes uncovered,opened,.and the interior of the tank inspected for the condition. 14,t.of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth9'of scum? F t �i /� .d' C '•! • .. .� «, AD'hf 1., ....-Y t t;� 4.S'a� : .. . V „H x; A ✓ :rWas the facility owner(and occupants if different from owner)provided with information on the proper. kwt4 `f i ';r't t :• nRx't ' utk 3 . k µ� ` ;maintenance of subsurface sewage disposal systems? w" � �_..r �..rE-�€S`�r�xC��'��3��-]s r'r.`cw� ;"�.3't, � � :✓tN at ,. r '�,.�ri "5,�"`.�;.r'�`�,,p cf�� l,t ta�f}� M.:�rr�.tl.t'`��a.�y`f n.^7t }t+{�.x asrn it z r s �t . f.+7, rl•7 3 by f a' '� g ti„ Y �c� 1- 7 q '1 t E V+ -u),b i Y.dY�/ a.• q �.. ktr'V. '° r + a Y S `''The size and location of the Soil Absorption System:jSAS)on the site has been determined based`on. 4 = � s•-S �F,erg�,S5�'t: �. .., '" Y : 8.. t �i +�' -..w�.�-.� ii'`i vet i.F:.. . ,Yes no ' + ' F•xt'�Existing information:For example,a plan at the Board of Health'. `'�" �'�y:� �: '' "`''{ { . t t` q a _. Determined mi the field(if any of the failure criteria related to Part Cis at issue approzunation of distance ` 4 ` '1 t is unacceptable)(310 CMR 15.302(3)(b)] ' S ,l y. ! k< - Yf '€�k5 ` " F "r F-#+�r1 s9 rtx,;f. ksa n. «.,?vim�`P,•�a i3.t� .::��a�'aF t"``k65�n k�:_'y.�r"r�r '.�{•'a �i cra,:,.. .t�At 47r-.rr;: t`s% :it �y;s..ix bpy ��rv?s-•1�• si' ♦- / a , ,g '{, .. � �'«, 4 r, I ii°.,r t r - ,? w fx> s � '•i+is r'"*4 ¢ „t �y�3.Pf.�:t��S S"� i:� nT f.� �r�p� ,y s4,r: '�}�ls•r F},�.1�e.., :,f mirky .t � R F t,.t .:r t i �akw .,t.« r c•.v^r-a �.+.unr wr^• rv-. s•_,r-:•-' _ 4 2 w � .wwew..r. -+7nw: nr J � .r..,..,.� r.1• .._•.• .,kF: z�1..1.� i :w.}q _.�. F*1,. - - t r ,r;�#izi..f•{;r! 'k� .}40� ,'..0 y�� C� - ; '�•,} � - f"'t -,4' '� �s��g/yy 11,8�.r't+ I't ,7•y",'4 t <4 a`;: ,e{', ` str n'k'?r}„y{ 3� .rj't �S 4:',�q, >7 h } .(flY fCf 5 + I;LySY,�y rr -.�.. g.* s*"t) fi s}x..t'ti) .1� 6iP j' J•' `c v t; .. Page 6 of`11 y OFC]LI�YINSPCTIONFORMs NOT FOROLiTAASSESSMEA'3S , SUB$��F,.AC °SEWAGE-,DISPOSALSYSTEM INSPECTION FORM. ,PART,.C SYSTEM INFORMATION Property Address: ' e, &,�i161/1, ' Owner 4 Lolra:r.e JAIh. I -Date of Inspection: 07— ?0- OL/ « FLOW CONDITIONS' ,. RESIDENTIAL, tl Number of bedrooms(design)::: .Number of bedrooms(actual):• 3 e, DESIGN-Aow based on'310 CMR 15.203 for exam"le:"110' d x4f-of bedrooms):", Number of current residents: 3 Does residence have a garbage grinder(yes or no):A/Q Is laundry on a separate sewage.,system.(yes or no) f.[if yes separate inspection:required] Laundry system inspected(yes or no) _ j.' � 9 o O ..Seasonal use:(yes or no): 0 jq.p' q o'o '. Water meter.readings,if available(last 2"years usage(gpd)) ;,r w4tK✓ �0 G` Sump Pump(Yes or no):_&g s; Last date'ofoccupancy: COMMERCIAL✓INDUSTRIAL;' 'j.. w ,.._...._... Type of establishment: Y DesigldecwW(based'on 310.CMR 15.203): aDd Basis of design flow(seats/persons/sg8,etc) Grease trap present(yes or no): Industrial waste holding tank present(yes or no) 'Non-sani waste discharged to the Title 5 system es or no : �'Y g Y (Y ) _ Y..Water meter readings;if available: Last.date of occupancy/use: ' ! OtiO R descnbe) GENERAL INFORMATION r Pumping Records Now Source of information: OwN.rs Was system pumped as part of the inspection(yes or no):ZVo If yes,`.volume pumped: gallons--I-iow.was quantity pumped determined? Reason :TYPE OF.SYSTEM _ZSeptic tank,distribution box,soil absorption system Single cesspool-overflow cesspool , Pn arcs;r`iuli,...::,.. c .:.,a_-?.rar.,:-a r :S p, + F. ;c a..T.�.,.:j .,•? ..Y ', ;1.? ., r Shared system(yes or no)(if yes,attach previous inspection records,if any)' Inuovative/Alternative technology.Attarh'a cgpy of the,iuireat operation and maintenance contract(to be :,,":,obtained, •x system owner), Tig fromt tank `Attach a copy of the DEP approval . Other(describe): Approximate age of all components,date ins%lled,(if known)and source of information: 160 'y Were sewage odors detected when arriving at the site(yes or.no).Al . a' a -Page 7'oh l l 4, + t�',',� �a I'„ ;l o..�i Lt' ;,..>,;;•Gct`s � .2 .:5 z.� ti:'> � r{ OFFICIAL:INSPECTION-FORM ;,NOT FOR VOLUNTARY ASSESSMENTS , : X SUBSUBkkCE'SEWAGE DISPOSAL SYSTEM INSPECTION'FORM s wy�s .kg7 r r<. j^ T , � ,pq }23 a x` { r•x p q .�. ,.S Aft;t�7 F; H�;i g...r 1t•p/*}.. PART V S1.X a�`.` s SYSTEM INFORMATION(continued) .. .•. ; .£ii."tx ..',:f.te M ,3r,.4cyry:y� t .:...Y�jY Y/rip`^�d t P 1'..��: Property Address: _ Je'f' h 1 '� •�� M �( -:'v �GY S�Di�S /�I MIS:: �? r� �� r - Owner: /YorY:�,4.. Date of Inspection• a—a 0-D r BUILDING SEWER(locate on site plait) ♦. �. '� �'" J`'-° ,•S.s'+� - >tiw t`"i r;,i',.+c�a Gs-.' a F r '? .i., :i r�.r.S Depth.below grade:•a ��, Materials of construction:_cast iron ✓40 PVC_other(explain): " Distanqe1rom.private water,supply well or_suctivil Comments(on condition of Joints,venting,evidence of leakage,etc) SEPTIC TANICi ✓(locate on site plan) ,Depth below grade:, �2 .. ,� y� Y ,�.�� is{,� ;� f a• a B 1_ Material of co tructiom. 'nS ✓concrete_metal_fiberglass.' .,polyethylene ,.�_,� -, :,.f � .,,�_ , .- •�,. . - other(explain) If tank is metal list age:_ Is age confirmed by;a Certificate of,Compliance(yes or no)_ (attach a copy of , certificate) - t .� ...,_ .- Dimensions: zz 0009 Sludge depth: ^-6'' r: 4. ^t r ,,, )r r{ Y f Y•; :.�'. :..`. r•;= Distance•from top of sludge to bottom of outlet tee or baffle 30 r Scum thickness:". 15s ;Distance from top of scum to,top of outlet tee orbaffle ..A ;f _ • °� i, �, ;Distance.flom bottom of.,scum to bottom of out let tee or baffle: , How were-dimensions determined:_ rnossv,-:' S --. ,Comments on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels `as related to outlet"invert,evidence of.leakage,etc.) ' �,I n 'f f' fT;��>�.,5 �.F �i,;�k-�+ ��a f•yhs o-�' L�r4,��` .•.-� �. i • �° .ran GREASE TRAP:_(locate on site plan) , a,: ti l�r„t T.n 4 d:•• s�•t ,J f4 ^ fr 1s 1t i..yi•.X� t 3..-,i.:�t '..�. s%11,. Depth below grade: > Matenal of construction �eoncrete metal - fiberglass_polyethylene other ,., (explain): x �., ._ . �.. , -.. 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(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels - • . as related to outlet invert,evidence of leakage,etc.):s ,. , Page 8 of 11 � ✓ Irv'#' r .'•.s •oe s -'_.r. '. y,Fgrr ,p +.:F.'7'w{t x 9.j..s �°'' v r C. 'a Pa t�, yi tip'* Y i -.x : '. 3 k;OFFICIAL"�INSPECTION�FORM :.NO"R:�� UNTARXASSESSMENTS y. A +. I SUBSURFACE'SEWAGE DISPOSAL :SYPTEM;INSftMON FORM:' til ?.e .,i•. arf�` d r ��."=$•$ 6{: _�.r ,•: tea �' _ , _ ;SYSTEM INFOPMATION(continued) G Property Address: r.+ `s .•; Owner. AYar,-74., Lvr.►,'�t :WAr',�t :x x Date of Inspection: r2-a?0- 05/ `TIGHT or HOLDING TANK. 'must be pum}ied at time of inspectioakSdtateon site plan) a { Depth below,grade: ,„:.• r '- st al of construction concrete metal fiberglass Dolyethylene other(explam) .F: Dimensions:, Capacity: ' gallons Design Flow:. gallons/day Alarm present(yes or no) , 7 = � yAlarmlevel s : , y 'Alarm is " 'Date Yof last pumpmg.I, s t k y` ,'1. rt, . _'•I. Comments(condition of alarm and Mat.switches;.etc) • � e t ui-.«`:-.2,; cf:� ii�; tC ! `;i "�; a ' t.s` {.. .::,c:.. r'.- - _ , DISTRIBUTION BOX: �'f resent must be o ened locate on site plan).... (1 P P. )( ). 1 _ i hf. .4 4 ;7:. A ��.._ { 5., t tif:L ,'J •. . ..De th of liquid level above outlet invert. Comments(note if box is level and distribution,to outlets equal,any.evidence of solids carryover;any evidence of 'leakage into or out of box etc.): fjf 7r) I.. t 1 It i1 t:t v, v � . i{ ,',ty. �,n .� tl•t..i t M1 is PUMP CHAMBER. r - (locate on site lan = _.._ , �.w......... 3 Pumps in working order(yes or no): -Alarms in working order(yes or no): Comments(note condition of pump chamber,condition ofpmnps and appurtenances, .a : ..va .,. p '^+ a t`:• . r ,, a C� � .r'i ,Y ,`,�? r� t _ a��SA•la l.�- c ,�. <?•- t ',,t,t .. t.. ., - f, •a. 3.t 3 i• t :l ,Y ;. 7Y * 1 ti0. �..� r r ,-&1JVyJ1J:{>iyllk1 cI.31t�1, f•.;y u.' J.J1: t1L�il�:{l411 t!llGt"t = )�3��4 1.3�l:��)�.=i� �' t t.PT �.-4`t`.4.f..1iF� t • . Xd ° r B Page 9 of I I H , ww f :lr, ..r+a .. • # �OFFIIAI, IpFC'�ION.FORM RIOT FOR':YOI:UNTARY"ASSESSMENTS 3 SUBS.URF_ACESEWAGE,DISP.OSAL:SYSTEM INSPECTION FORM : - ,�, • - . ' PART C_, SYSTEM INFORMATION'(contitiued) Property Address: 0.11.4 f 'Lh .. Owner: vv✓n ao-, ¢ Larra,'.�t !y� 'f e Date of Inspection: -.70-oy . .. SOIL ABSORPTION SYSTEM(SAS):. ►/(locate on site plan,excavation not required) If SAS not locatsd explaut;why Type ,eaching pits,number: leaching chambers,number. ' leaching galleries;number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: innovadve/alternative system-,Type/name of technology:. Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, Y etc'.):' i .� =�.. `«��.... . . V }t` CESSPOOLS. .(cesspool must be pumped as part of ins' don)(locate on site plan) Number and'configuration: Depth-top of liquid to inlet invert: `Depth of solidi layer: Depth of scum layer ,'Dimensions of cesspool: i .Materials of construction:, Indication of groundwater inflow(yes or no): - Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: (locate on site plan) Materials of construction. . f-:Dimensions•:`' t s 5:`Depth of solids: `:5 :Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): by t: a Y.{ yi ! o y L as K y' ' p t , r .,., ax Syr' ?,�',.-'J y''"l,S,; x;q!�'+•dt, ':} IIII II P P+pf ,rS irr"'�SFm "' rkY,..ft J {i Fti ti.f A,"_ "A, S r Page 10 of 11 ;Lrr T W{ ! t fi. rt� n'Fx•tr �'- s r'3 et k k. r :x - k YF1 dr ° k'i?.':A R �-.r f �T.fpY`1A '7ti,F�.n },V;7. J�, ;+ v. - r ..r K1N . e♦arr 7. t �_. x{r.1j••(� ._,, _ ' - u . r r , k , ' F CTIO .ORM yNOTFOA-VO� WAY,t ASSESSMENTS 'jf a � F " ,� SUBSURFACE SEWAGE DTSPQSA�`SYSTEM INSPECTION FORM J x�r � _'W",l , y � `2 � rr7i•a FA T ' ': a �J Y' ,,^' ♦ a4 r h. :+ [t I�xr � 4't' .,d"f{ Sa -:.� ;'"a�•„44J +;�?; Ct rr. a , A a,S"I _3�Y•F� ri�2�t ''�i a '. any Crr> ( q... t ,..at i M l.e+; r, S, �'4' ^ ' ' .'SYSTEMINFORNI TION(coatii 'd) `' rr J y e t i s � t` rat d a s •'c ••s a,2 .J 5 r �', a„ t, � ? r .i t �F, t �+Y .4 k b :.L• t . Ra.,�...•t {.♦ ,�t:a ,S t ,a ty'k i ' . a'"�7�4 tyy fla8r"4`;4.!a���T,���"t"s�,� F`, tia�S♦t r a f t f'•'n`trt i k 7 Y 'E' 1, c h Y r� I •. t r }YiS4+5•'" I .a F'"""l� tsa, ✓r .vf�' t ,t t.0` t L 1 F-' ,��. S + ;� .,,f ; z. 4 a 5' rx' M,y`i : e i.r„:r tld r„ 3, t,•-... Y r , .: Pro a 'Address.'` r... ,fk'S j�r t ; t\ a fPriY " , 2 i'{. ,SYR t''r-„? sj1 r.o-•1, a .J- I, p :}x w �s,tr 1 �;.G Y ? _ t 4. . r 1.•,rt r s " kza r Yt w-`;:/t♦/er f t- l — 4 j+�/� ,, 3 ,.e° �.a,.' + I. Owaer:-_ �(/._ L,,wa .e: Wh;to '. ,y S��i{a_& Data 0+i8i ec�{oni tr T rli k s i it7a r rth � . tt�, p To oy 4 , j�t tta'. � 4+ b �.'i"iyn 4,s'' `{Y� f 7 {�w,a4a a1,4'-`:, 11 L .� °ti a 1r-Y rt MdJ rsaa ayZ" y a�:ett {y't:_ -� .rr r:'4� ' � ;4 a r..a . F " .: ' t r ,JSKETCH OF SEWAGE DISPOSAL SY3TE&ir ..• • •'.a• .. . ,; x, # Provide a sketch of the se""wage disposal system includmg'ties to at least two permanent efererice laudrnarks or ; adr I k 1 ,benchmarks.Locate ali wells witlua 100 feet,Locate where public water.supply.eaten the building. t .�.," *+} "' •�j',kFrti.,.issodKt�"y3K+,.+t,u,r+c•••+;s.sx* .t, n 1t F'f ? ti •l ';�q•.Y 11! 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