HomeMy WebLinkAbout0218 CAMELBACK ROAD - Health 218 CATdELBACK ROAD,M-44UkS
A= 047152 D`' �- s S
r
p- TOWN�OF BARNS ABLE
1r``-"���TTON
- a% ( aZ `�})qQ-y-V44 SEWAGE #
VILLAGE�� � `� ' `���� ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY 1660
LEACHING FACILITY: (type) 11 !�� '� (size) 1"F0 O()
NO.OF BEDROOMS
BUILDER OR OWNER w�bS
PERMTTDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by �cC.[
I
i
IL
......,_.._+.vw........._........_............ ........._........ "•') .._.... .................P....._._......._......._.. "' ice^)- .'i' •.,.,.��.1-�; i Y~6.,.'?..J�......
TOWN 111F BA NSTABLE
6 l
f
'LOCATION V al SEWAGE
VILLAGE ASSESSOR'S MAP_ & LOT
3
INSTALLER'S NAME & PHONE NO. / ekO / Qp�Ai_l
^ / 3-gs-
0
ASEPTIC TANK CAPACITY /®U U
r I
`LEACHING FACILITY:(type) 1
kNO. OF BEDROOMS 3 PRIVATE WELL O PUBLIC WATER
b t
BUILDER OR OWNER
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED: � (tt
VARIANCE GRANTED: Yes No ��
O
3
N0.25L..- l2Cr' ,. FRs...........................
_
THE COMMONWEALTH OF MASSACHUSETTS
al BOAR® OF HEALTH
I 0
........... ....................oF.........�. P-N �.
4 A110ir-ation fnr Utipnsai Works Tvn.otrurfiun ramit
PApplication is hereby made for a Permit to Construct ( wl)�or Repair ( ) an Individual Sewage Disposal
System at: /
................_..cat-eL-t c.,_-•----)2 ................... ....... ----------- [ ........ ... ......
..
Loc Address or
�- /�/5 i4i2 Con/s-: �n/O flP�►?ou7N /�/�,
Owner Address
W
Installer Address
Type of Building Size Lot..24Z alzst..Sq. feet
Dwelling—No. of Bedrooms............��..............................Expansion Attic ( ) Garbage Grinder ( )
a'4 Other—T e of Building No. of persons............................ Showers
YP g ---------------------------- ---- ---------- ( ) — Cafeteria ( )
Otherfixtu es ..---••••------------•--•------•--•----•-_ ----------------------------------------
W Design Flow............V�..�....................gallons per person per day. Total daily flow__-_-:.........36................._...gallons.
WSeptic Tank—Liquid capacity/8!V..gallons Length_,::/?" Width.6L O��._. Diameter................ Depth��'3'�.
x Disposal Trench—No..................... Width.....__............. Total Length....../._.............. Total leaching area---_.,__p._._._....sq. f .
Seepage Pit No....._..-_I-__-__-- Diameter.. �.'_ ��... Depth below inletl�,=®.�.... Total leaching area..Y'_Z7...*Wtt.,&� �
Z Other Distribution box (,/j Dosing tank ( ) /
aPercolation Test Results Performed by w___ �l�h��✓�--�!!✓ .1!✓C_. Date. /7/X, ................
Test Pit No. I.....2......minutes per inch Depth of Test Pit....114. .......... Depth to ground water./V /.✓5-____-
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
-�• ----------------------------------------•--......-•-•--------............---------
O Description of Soil....-.�......../..aP_.. .S4<!! LZ_....
U .................................................... ..
x --------------------------------- ------- .......MOD....5��,/D.........................................................................................................
U Nature of Repairs or Alterations—Answer when applicable._.._._.........................................................................................
---------- - --•---•---•••----_-•-•----•---•--•---••---••--••-•••--•--•-•-••-•-..........
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TI APLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been ' sued by the bo f heal
------ ••. ..........................
Date
Application Approved By....................... •.---•- •. . .................................. .........
Date
Application Disapproved for the following reasons---------------------------------------------------•-•--•----------------•----•--•-----•---•• •-----------•--...
.............................•-------•--......--••-•------........---------=--•-•------•---•--•----------••---------•-----•-•-----•_----_--_-----•---•-----•------•_------------•• -----------....••---
Date
PermitNo------------- ----•- •--2-C D Issued.......................................................
Date
_ Al
No. Co
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Applira Lion for 14spaaii al Norks Tonstrur#inn Prrutit
Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
System.at: s
............. .: 1: f....... . .... .... ....` .....--•---....... -•----. ....-------- ... .....---•--••----. ...._.__......_.
i` Yt
r fX......................................
f Locatapn Address
............... ... .
tr.... ....,.CJ, i .. ........ ... Ir � � or Lot.N•o� � .. ;
W Owner Address
Installer Address 4Y, f
d Type of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
Other—Type T e of Building No. of persons............................ Showers —
� YP g ---------------•---•-------• P ( ) Cafeteria ( )
dOther fixtures ------------------------------------------------•-•---------....-•---------•------•--------------•------ ---...----••-•--------.....----------------
W Design Flow.......... :' �....................ti..gallons per person er day. Total daily flow.._........_.......f�........ .._.____....gallons.
WSeptic Tank—Liquid capacity.�Y)0.gallons Length..::..._.'`.. Width__�:.°i -- Diameter................ Depth.per_.:......
x Disposal Trench—:�?o..................... Width.............._..... Total Length__.........___._.._ Total leaching area........ .__. Sq. ft
Seepage Pit No.................____. Diameter....._...... �..... Depth below inlet. .:r....f`...___ Total leaching area.._.`_r..4__.._:_...sq, ft. y
Z Other Distribution box Dosing4tank ( ) '
Percolation Test Results Performed by......`.... . _...._ _.......... ...... Date........................................
�. Test Pit No. 1_-__--9......minutes per inch Depth of Test Pit..... .......... Depth to ground water �'1,9/`....=
fTq Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
0
---
Description of Soil .. 5
....--•---------•-------•-----•------------------------------- ------ -..
UNature of Repairs or Alterations—Answer when applicable._..............................................................................................
--------------------------------•--••-----------•----------•---•--••---------------......----......-----••--------.....................................-...............................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TLITTIE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been/ri'ssued by the board bf health
Sig_ned......fr_..:! ..................................................................
................................
r �+ Date
Application Approved BY C c _! �,fL. . :�.�.----------•----------- ----•--
1 4a �-........
/ Date.' b
Application Disapproved for the following reasons----------------------------------------•--........-----------••----------------•------------•--•------••......-
•-••----------------------------------••----•------•-----------•-•...----•------•------.....------....-------•-----•--...----------------------•••-------•-•--•--•----------••---------•-•-------------
Date
Permit No.- � t 1 Issued
£ Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
............. . ...............OF...............:" ..`...... ...`..` : ......................................
TrriifirFair of TompliFaurr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ("/Tor Repaired ( )
by---------......................................... �''==a....i!`f�h��= • ----
Installer
. � 1
at ........---•---------------•--•---•------------------•••._...-----•-----------...••--•------------......----•-----------
has been installed in accordance with the provisions of T1TIE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No ,------- _GJ. dated......�_b4__NTEE
�.. _1 .._._.._...
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GBJA THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE.....................1. _ �./f..l .......................... Inspector--------..........---)..... ..........................................
THE COMMONWEALTH OF MASSACHUSETTS
G, BOARD OF HEALTH
1
l
�"—"--- - .................................. �.................. �_... .._...... ...:.....:........................
4� � ..... FEE...
...
............ - '77-�
Disposal Workii Tnn trudiou rrutit _
Permission Is hereby granted :................................--...... -••-•--•..........................7..............--
to Construct ( ' ) or Repair ( ) an Individual Sewage Disposal System
at No
' /*)
Street
as shown on the application for Disposal Works Construction Permit Dated..�___
DATE------.!•-----. .-._zy..___ ..................................... Board of Health
FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS
t�
Commonwealth of Massachusetts
Executive Office of Eiivirolunental Afairs
Dept. of Environmental Protection ON
One winter Street Boston,Ma. 02108 John Gi Ad
D.C.P. Title V Septic Inspector
kip P.O. Box 2119
Teaticket, MA 02536
wILUAM F.wELo (508)564-6813
Governor
ARGEO PAUL CELLUCCI
Lt.Governor
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: 218 CAMEL BACK RD.MARSTONS MILLS MAP 047 PAR 152 Address of Owner:
Date of Inspection: 10l23l98 (if different) � Q
j�
Name of Inspector: JOHNORACI PASSIOS
I am a DEP approved system inspector pursuant to Section 15.340 of Title%(310 CMR 15.000)
Company Name,Address and Telephone Number:
t
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
x Passes This Inspection Is based on criteria defined In Title V
code 310 CMR 16.303.My findings are of how the system is
_ Conditio all Passes performing at the time of the Inspection.My inspection does
Needs r er Evaluation By the Local Approving Authority not Imply any warranty or guarantee ofthe longevltyofthe
septic system and any of Its components useful life.
Fails
Inspector's Signature: #ubmit
Date: 1on419s
The System Inspector shall a copy of this inspection report to the Approving Authority within thirty(30)days of completing this
inspections. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit
the report to the appropriate regional office of the Department of Environmental Protection.
The original should be sent to the system owner and copies sent to the buyer,if applicable and the approving authority.
INSPECTION SUMMARY:
Check A, B,C,or D:
A] SYSTEM PASSES:
x I have not found any information which indicates that the system violates any of the failure criteria
defined as in 310 CMR 15.303. Any failure criteria not evaluated are indicated below.
COMMENTS:
B] SYSTEM CONDITIONALLY PASSES:
_One or more system components need to be replaced or repaired. The system, upon completion
of the replacement or repair,passes inspection.
Indicate yes,no, or not determined(Y, N, or ND). Describe basis of determination in all instances. If "not determined",explain why not.
The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of
Co7hpliance(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 conforming septic tank
as approved by the Board of Health.
(revised 0412757)
One Winter Street a Boston,Massachusetts 02108 • FAX(617)556-1049 • Telephone(617)292-5500
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Add re SS: 218 CAMEL BACK RD.MARSTONS MILLS MAP 047 PAR 152
Owner: PASSIOS
Date of Inspection:1ar23199
_ Sewage backup or.breakout.or hiah.static water level observed.in.the distribution box is due to a broken.
or obstructed pipe(s)or due to broken,settled or uneven distribution box.The system will pass inspection if
(with approval of the Board of Health). Describe observations:
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
—The system required pumping more than four times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require further evaluation by the Board of Health in order to determine if the
system is failing to protect the public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS
NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND
SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER,IF APPROPRIATE) DETERMINES
THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
The system has a septic tank and soil absorption system and is within 100 feet to a
surface of water supply or tributary to a surface water supply.
The system has a septic tank and soil absorption system and is within a Zone 1 of a public watersupply well.
The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that
the well is free from pollution from that facility and the presense of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm. Method usedto determine distance (approximation not valid)
3)Other
D] SYSTEM FAILS:
You must indicate either"Yes"or"No"as to each of the following:
_ I have determined that the system violates one or more of the following failure criteria as defined in
310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be
contacted to determine what will be necessary to correct the failure.
Yes No
Backup of sewage in facility or system component due to an overloaded or clogged SAS or
cesspool.
Discharge or ponding of effluent to the surface of the around or surface waters due to an.overloaded or r.1naged
cesspool.
SAS is in hydraulic failure.
(revlaed 04r17)97)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 219 CAMEL BACK RD.MARSTONS MILLS MAP 047 PAR 152
Owner: PASSIOS
Date of Inspection:10/23198
D] SYSTEM FAILS(continued)
Yes No
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Numbers of times pumped
Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
Any portion of a cesspool or privy is within a Zone 1 of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform+bacteria,volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E] LARGE SYSTEM FAILS:
You must indicate either"Yes"or"No"as to each of the following:
The following criteria apply to large systems in addition to the criteria:
_ The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to
public health and safety and the environment because one or more of the following conditions exist:
Yes No
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area(IWPA)or a mapped Zone II of a
public water supply well)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(reyleed 04127)97)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECLIST
Property Address: 218 CAMEL BACK RD.MARSTONS MILLS MAP 047 PAR 152
Owner: PASSIOS
Date of Inspection:10/23199
Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following:
_c_ — Pumping information was requested of the owner, occupant, and Board of Health.
x None of the system components have been pumped for at least two weeks and the and the system has been receiving normal
— flow rates during that period. Large volumes of water have not been Introduced Into the system recently or as part of this
inspection.
x As built plans have been obtained and examined. Note if they are not available with N/A.
x — The facility or dwelling was inspected for signs of sewage back-up.
x — The system does not receive non-sanitary or industrial waste flow.
—x_ — The site was inspected for signs of breakout.
x All system components,excluding the Soil Absorption System, have been located on the site.
x The septic tank manholes were uncovered, opened,and the interior of the septic tank was inspected
for condition of baffles or tees, material of construction, dimensions, depth of liquid,depth of sludge,depth of scum.
x The size and location of the Soil Absorption System on the site has been determined based on
The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of
Sub-Surface Disposal Systens.
x Existing information. Ex. Plan at B.O.H.
x Determined in the field(if any failure criteria related to Part C is at issue, approximation of distance is
unacceptable)[15.302(3)(b)]
;reyiaed 04127197)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 218 CAMEL BACK RD.MARSTONS MILLS MAP 047 PAR 152
Owner: PASSIOS
Date of Inspection:10123199
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 330 g.p•d./bedroom for S.A.S.
Number of bedrooms: 3
Number of current residents: 4
Garbage grinder(yes or no): No
Laundry connected to system(yes or no): Yes
Seasonal use(yes or no): No
Water meter readings, if available:(last two(2)year usage(gpd):
nfa
Sump Pump(yes or no): No
Last date of occupancy: nIa
COMMERCIAL/INDUSTRIAL:
Type of establishment: nla
Design flow:0 gallons/day
Grease trap present: (yes or no) No
Industrial Waste Holding Tank present:(yes or no) No
Non-sanitary waste discharged to the Title 5 system:(yes or no) No
Water meter readings, if available: nfa
Last date of occupancy: Na
OTHER:(Describe) rda
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
SYSTEM WAS LAST PUMPED 2 TO 3 YEARS AGO,INFORMATION FROM OWNER
System pumped as part of inspection: (yes or no)No
If yes,volume pumped:0 gallons
Reason for pumping: nfa
TYPE OF SYSTEM
x Septic tank/distribution box/soil absorptions system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no) ( if yes, attach previous inspection records, if any)
I/A Technology etc.Copy of up to date contract?
Other:
APPROXIMATE AGE of all components, date installed(if known)and source information:
SYSTEM IS 10 YEARS OLD.
Sewage odors detected when arriving at the site: (yes or no) No
(revised 04127197)
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 218 CAMEL BACK RD.MARSTONS MILLS MAP 047 PAR 152
Owner: PASSIOS
Date of Inspection:10123199
SEPTIC TANK: X
(locate on site plan)
Depth below grade: 3"
Material of construction:x concreate_metal_FRP_Polyethylene_other(explain)
If tank is metal, list age nia . Is age confirmed by Certificate of Compliance Nc (Yes/No)
Dimensions: Le'e°H5-7--W4'10--
Sludge depth:4"
Distance from top'of sludge to bottom of outlet tee or baffle: 30'
Scum thickness:"'
Distance from top of scum to top of outlet tee or baffle:S"
Distance form bottom of scum to bottom of outlet tee or baffle: 17"
How dimensions were determined: MEASURED
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage, etc.)
SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND.RECOMMEND PUMPING EVERYTWO YEARS.
GREASE TRAP:
(locate on site plan)
Depth below grade: nra
Material of construction: _concrete_metal_FRP_Polyethylene_other(explain)
Dimensions: rya ,
Scum thickness:rda
Distance from top of scum to top of outlet tee or baffle:rda
Distance from bottom of scum to bottom of outlet tee or baffle: ria
Date of last pumpingr".
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage, etc.)
nfa
BUILDING SEWER:
(Locate on site plan)
Depth below grade: 12"
Material of construction:_cast iron x 40 PVC_other(explain)
Distance from private water supply well or suction IIne:TOWN
Diameter: nla_
Qmments: (conditions of joints,venting,evidence of leakage, etc.)
(revised 04127)971
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 218 CAMEL BACK RD.MARSTONS MILLS MAP 047 PAR 152
Owner: PASSIOS
Date of Inspection:10f23198
TIGHT OR HOLDING TANK:
(locate on site plan)
Depth below grade: rda
Material of construction:_concrete_metal_FRP_Polyethylene—other(explain)
Dimensions: nfa
Capacity: nfa gallons
Design flow: Na gallons/day
Alarm level:_wa Alarm in working order?_Yes_No
Date of previous pumping:
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
nfa
DISTRIBUTION BOX: x
(locate on site plan)
Depth of liquid level above outlet invert: LIQUID LEVELwITH BOTTOM OFPIPE
Comments:
(note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box etc.)
DISTRIBUTION BOX IS STRUCTURALLY SOUND.
PUMP CHAMBER:
(locate on site plan)
Pumps in working order:(yes or no)No
Alarms in working order(yes or no)_Ye:
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
Na
(revised 04477)97)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 218 CAMEL BACK RD.MARSTONS MILLS MAP 047 PAR 152
Owner: PASSIOS
Date of Inspection:10/23199
SOIL ABSORPTION SYSTEM (SAS):x
(locate on site plan, if possible;excavation not required, but may be approximated by non-intrusive methods)
If not determined to be present,explain:
Na
Type:
leaching pits,number: 1000 GALLON LEACH PrT
leaching chambers,number:rda
leaching galleries„number: rJa
leaching trenches, number,length: rda
leaching fields, number,dimensions:nla
overflow cesspool,number:nla
Alternate system: rda Name of Technology:_nra
Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.)
THE LEACH Prr IS STRUCTURALLY SOUND AND FUNCTIONING PROPERLY.PIT SHOWS NO SIGNS OF FAILURE.
CESSPOOLS:
(locate on site plan)
Number and configuration: rda
Depth-top of liquid to inlet invert: rda
Depth of solids layer: rva
Depth of scum layer: We
Dimensions of cesspool: ria
Materials of construction: rda
Indication of groundwater: rda
inflow(cesspool must be pumped as part of inspection)
rda
Comments: (note condition,of soil, signs of hydraulic failure,level of ponding,condition of vegetation, etc.)
rVa
PRIVY:
(locate on site plan)
Materials of construction: rda Dimensions: r9a
Depth of solids: rda
Comments: (note condition of soil,signs of hydraulic failure,level of ponding, condition of vegetation, etc.)
nra
(revised 0427)97)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
218 CAMEL BACK RD.MARSTONS MILLS MAP 047 PAR 152
PASSIOS
10123/99
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)
LirA
0�
A c' AC COL
gO 51�
Irevtaed04127197) Page ! of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
218 CAMEL BACK RD.MARSTONS MILLS MAP 047 PAR 152
PASSIOS
10123/99
Depth of groundwater 12
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from design plans on record.
Observation of Site(Abutting property, observation hole, basement sump etc.)
Determine it from local conditions
Check with local Board of Health
Check FEMA Maps
Check pumping records
Check local excavators, installers
Use USGS Data
Describe in your own words how you established the High Groundwater Elevation.(MUST be completed)
USGS MAPS AND CHARTS
(revised04127197) rage 10 of 30
� II
V
L � AOTEt5�IT. OWN A RE 141, Fk, 4710N,5 59 o
t-CH- A 4:P17 MIMMI-IM OF 00 tt4,C 01V 4OR 50-146,P111.DO(D: 000�j 0- 0 rl MRIA 4�tME�0 'WIT Y,i0 @eQ C./, NIMIF C4.4 Y
a4 Mk AM VIAG�4 t (3) 0- �(D t47
P, C .4710N
-0.40r P4-R:'1NCH'6R ke,55 r/ ox 77 IA! 4/574,rq R 4 t -A/ 7#4 V N07, t""IC 7' ro-A4e*c,1z;�By S C,ZANK 0 � 1 �7 4W4--Q41 Ic N e,?,r-0,,,(ST40,o`?' b A i;rA ff-4 r,0-'o/v -WkLE ',IN NOr <7 6C,4446 IN Lb -E- ,UNKS:�,A 07 7 ,N R rz r!elR' L r�q rR14 c W,6 A p 10Y'40CW��RIO,49$ /A( MR A.A�:PO rr().R.RAT9 IENGINZERINIG INC
IF elP lFA0p OL ttACC io5 Y16 56: A*(g tAO 4 E Al, E ovjffQ�-Sp- *,P* 4&OX t16 IF- tttt � V 4E C2.-tT'll Y , 16 1;71 ttII�'2 4 00 H-Z,O' P e ttIW474 14 SYWEW 0 A
EMA
-ONS:p P&SON, PAY'tZ tRCMA r Itr4v7W: Z-5
ft
41N I �a Y�l V tE