HomeMy WebLinkAbout0049 CARDINAL LANE - Health .Cardinal , ane
MarstonsWills P
a A A—,PU •021
LOCATION SEWAGE PERMIT NO.
VILLAGE
INSTALLER'S NAME i ADDRESS
B U I L D E R OR OWNER
D/t��,2• SSdc.
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED
6r
�le
/olc�.✓ L7/�f
Board of Health
Town of Barnstable
No...... P.O.Box 534 a F�s... �...................
�� Hyppj� Issachusetts 02601
NWEALTH OF MASSACHUSETTS
BOARD OF HEALTH*
lam' ....------.-•--OF.............................................
Appliration for Bisvvii ai Works notrurtinn rranit
Application is hereby made for a Permit to Construct ( or Repair ( } an Individual Sewage Disposal
System at
qa-x 6ati ni Add � :...............................................................or Lot No.
......<_.._.._ ........... .............. ..... ._.. ......_...
O ner � -•Address
w ------------------- - -------•-•-•• ----- -••- .... -------.....•---------...-----.---------- ...---------....:------------....._..------
Instal Address
Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms_______._...........................Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building No. of persons____________________________ Showers — Cafeteria
aOther fixtures ....................................................................................................................
W Design Flow..........�ZP _______________________gallons per person per day. Total daily; flow.:_._________.__�._�.____`�____.__.____.gallons.
WSeptic Tank—Liquid capacit/C�AP.,.Q.gallons,.: Length__ B`_____ Width_ ........ Diameter________________ Depth__. '___.._-
x Disposal Trench—No_____________________ Width_____:::_._.. . Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No.../------------ Diameter._Zj2.r_`57._ Depth below Total leaching area_.=.��' Pt..sq. ft.
Z Other Distribution box ( Dosin 'tank ( ) ��&�e_ C>,%j
Percolation Test Results Performed by- "?_..�. �:� �� ' �-- --------------- Date._----••----.. .._...Pa Test Pit No. 1�_.�t3iinutes per inch Depth of Test Pit______f Depth to ground water_.___. . ..
w" ..Test Pit No. 2................minutes p"er inch Depth of Test Pit.................... Depth to ground water........................
----------•--••--••-----•-•----•-•--•----------.....................
��
O Description of Soil -._..../ _G '? a ---
W ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------••-•
UNature of Repairs or Alterations—Answer when applicable--------------------------------------------------------
---•---•-------------------•---.....-----------------•----•---------------------------•-----•----•---•-........•-----------------•-----•------------------•••-----•------•••--.......................
Agreement
The undersigned agrees to install the af; described Indio a ewage Disposal System in,accordance with
the prow` ions of TITLE 5 of the State Sa tary ode—The dersig ed further agrees not to place the system in
operat unt a C- ti of Complianc has b e issued he boar of health.
i
e . S gned•- - --....
� Date
Aat' n Approv By........................................... ---- --• --- - - --------- ��-------------
bate
Application Disap roved for the following easons......................................
-••-----•-----------------•-=•--------.._..--•--......---._.......--.----------•-•--._...-•-----------...---...--•------------------------------••••. ---------------<--•-•----------•---.......
Date
p . .
Permit No.__-Q.�_- --�. 1{ ____________________ Issued..........LA _. V._..................
D
No..,�t`f„�! ✓- F�a�� ......................_
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH'
-------- - .. .... -..-.OF.....................................:.... _.
Appliratilan for Disposal Works Tonstrnrtiun Frrmit
Application is hereby made for a Permit to Construct (V,) or Repair ( ) an Individual Sewage Disposal
Systemat: A -•----•- ......................................
/ ��Location-Address or Lot No.
✓ �' "N0 tic f= t/
^ �.
.... ... .... ...... -----..._....---•--•--------•--------•--•• ..........--••---...-•----......-•---..._.._.. --------••- ----.................
••------------
Owner Address
W
Installer Address
Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms---:.:__............................Expansion Attic ( ) Garbage Grinder ( )
aOther
—Type of Building ____________________________ No. of persons............................. Showers ( ) — Cafeteria ( )
d . Other fixtures -------------------------------•----------------------••••-•---•-•--•-----••-••-•••••----------••--------••- ---
W..
Design Flow......... a�_.......................gallons per person per day. Total daily flow............................ ............gallons.
riW Septic Tank—Liquid capacity' 7jgt_gallons Length_r3......... Width4 ......... Diameter________________ Depth....
Disposal Trench—No_____________________ Width_____.__ ____ Total Length.................... Total leaching area.......__............sq. ft.
Seepage Pit No._ ____--------- Diameter._ :.5.... Depth below inlet_�__.`�_.___. Total leaching area...«_ ...sq. ft.
Z Other Distribution box Dosing tank 7��"`�
"+- Percolation Test Results Performed by..................................' ?C_ '`��______________ Date_____ _ .___..
..
.� .. Test Pit No. 1 _. 7 minutes per inch Depth of Test Pit-----/ ._. Depth to ground water________________`.`
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
r, I O .� �__.....� .. ... ...........� � ......................................................... ..
Description of Soil ---•---------�-`-_-•----•---a':__�------' � ?
x • f
- ------•-- ----- - ••--------------------------------------------------------------------------------------------------------------------•----y-------------------------- -- - ----•--••-
PIPp I ature of Repairs or Alterations—Answer when applicable................................................................
<:
1 ..................:................................................................................................................................
Agteemeirt-•
The undersigned agrees to install the,.,afbredescribed Ind�i idu Sewage Disposal System in accordance with
the provisions,of TITLE 5 of the State anita� Code— 'I, /under gned further agrees not to place the system in
operation til a Certificate Compliance has b e issu by the b rd of health.
r .
Si ned F x
g --- ---------------••-------- -•-------------------•-----
r f Dat
Appl proved y ------••••. •--- ........... - .... - ------ �•�,.�!�f'��y••-•------
Date
IN
Appli tion Disappr ed for the follow g reasons:••••-------•--•-•-••--•••--••- • •••-•••---••-•-••-•••••••-••-•-••..........................................-
................•••••-------•••-----• •-•-•••-•----`••••----..._...-••-----------•--•-•--•••••••-- -•-••- -------------------------------•• -••-•---•------••-•-•-•--•-•- -----
Date
Permit No. ... Issued - '
r ....._..._.
THE COMMONWEALTH OF MASSACHUSETTS
BOARD. OF HEALTH „
1
..........................................OF........'.............._..-............_......_.._......................'..._.......
Tnt f iratr of TuntpliFanrr
THIS IS TO CERTIFY, Tha t e Individual Sewage Disposal System c structed ( or Repaired '( )
by ----- ---- ' ---------------------------•----•--------
r Instal er r
has been A'st�ltd in acArdan�e Witt th rovisions of TITLE 5 of The State Sanitary Code as de ribe in the
application for Disposal Works Construct ,n Permit No...... �.�-_,,��,1�_____. dated__--------.�__�_._ _�_�_ _____________
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONS UED AS A GUARA T THAT THE
SYSTEM WILL FIJ N TtnN SATISFACTORY.
DATE. 4-1,7 ........ Ins ector-------------- - - ........ ----••-•--•---•----•--••......._
�,
t THE COMMONWEALTH OF MASSACHUSETTS IE
ABOARD OF HEALTH
...........................................OF...............................................
..._.--.....-..-.._....:.._......_....
No...... _• FEE...S.. ...........
Ala;
nr �nn�trnrtuan� prntit .
Permissionis hereby granted_.__.__t ::a . . �4,�-eq------------------ --• •--•----••----•...•-•-•-••••••-••-.......----•••..........••--•••..._..
to Construct ( ) or Repair ( )`tea �a vidu Sev,age Disposal System
atNo.................... -•••• - ----•••..............
k� � +' �Ve treet y
as shown on the application for Disposal Works Construction Permit No____________________ Dated.........................................
;.
r
DATE.......`°=......Z /`{ �i.................................. 5. Board of Health
FORM 1255 A. M. StULKIN, INC., BOSTON �
ST Z�4`1
COI�MON�NTEALTI-I OF MASSACI-T SETTS
EXECL"I'IVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTLDECI
PION
p i4
.r'
RCEl. � 2 04ABLE
.
TITLE 5 —;
OFFICIAL, INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS' '
SUBSURFACE SEWAGE DISPOSAL. SYSTEM FOR? ! CD
PART A
CERTIFICATION - J
Property Address: k,&,-.A. s
Owner's Name: �-�
Owner's Address: `
a
V
Date of Inspection: l►1 :2-0 10 e� ee
Name of Inspector: please print)in,-CL6.,el
Company Name: `N1b0 &"y)S
Mailing Address: 'V0'ZSg aglo
Telephone Number:
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP
approved system inspector pursuant to Section 15340 of Title 5(310 CMR 15.000). The system:
Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: Date:
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or
DEP)within 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,if applicable,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 6/152000 page 1 I
Page 2 of 11
'
OFFICIAL.INSPECTION FORS-,NOT FOR V®IVOLUNTARYA�Y ASSESSMENTS
SUBSURFACESEWAGE DISPOSAL SYSTEM INSPECTION FORM
- PART A
CERTIFICATION(continued)
Property Address:
Owner: .`�+e�
Date of inspection: AgkO�
Inspection Summary: Cheek A,B,C D or E I ALWAYS complete an of Section D
A. System Passes:
AI have-not found any information which indicates that any of the failure criteria described in 310 CMR
1530 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 ihe`'Conditional Pass" 'on need to be replaced or
repaired.The system,upon completion of the replacement or repair,as ap ved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND)in the for ollowing statements.If"not determined"please
explain.
The septic tank is metal and over 20 years of or the septic tank(whether metal or not)is structurally
unsound,exhibits substantial infiltration or exfil on or tank failure is imminent_System will pass inspection if the
existing tank is replaced with a complying tak as approved by the Board of Health.
*A metal septic tank will pass inspection i ' is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 y old is available.
ND explain:
Observation of se backup or break out or nigh static water level in the distribution box due to broken or
obstructed pipe(s)or due a broken,settled or uneven distribution box.System will pass inspection if(with
approval of Board of H th):
broken pipe(s)ane replced
obstYtutim isTmoved
distnTnition box is bled or replaced
ND expl
e system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will
pass on if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
2
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Page 3 of 11
OFFICIAL, INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL. SYSTEM INSPECTION PORN
PART A
'r CERTIFICATION(continued)
Property Address: 7 t*j
s �i S
Owner: k8me, `
'!Date of Inspection:
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in order to dete ine 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 3 CMR 15303(I)(b)that the
system is not functioning in a manner which will protect public healt afety 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 etland or a salt marsh
2. System will tail unless the Board of Health(an blic Dater Supplier,if any)determines that the
system is functioning in a manner that protects t public health,safety and environment:
_ The system has a septic tank and soil rption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a s ce water supply.
— The system has a septic tank SAS and the SAS is within a Zone I of a public water supply.
_ The system has a septic and SAS and the SAS is within 50 feet of a private water supply well.
The system has a sep' tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply we *.Method used to determine distance
"This system pas if the well water analysis,performed at a DEP certified laboratory,for coliform
bacteria and volat'a organic compounds indicates that the well is free from pollution from that facility and
the presence of onia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteri are triggered.A copy of the analysis must be attached to this form.
3_ Oth r:
3
Page 4 of l l
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DAPOSAL SYSTEM INSPECTION FORM
PART.A
CERTIFICATION(continued)
Property Address: C.
Owner: t
Date of Inspection:
A 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
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 1/2 day flow
( Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
of times pumped
Any portion of the 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.
�Y 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.[This system passes if the well water..analysis,
performed at a DEP certified laboratory,for colfform bacteria and volatile organic-compoweds
indicates that the well is I.ce from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equat 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.]
(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
You must indicate either`yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to criteria above)
yes no
— _ the system is within 400 feet of a s ce drinking water supply
— the system is within 200 f of a tributary to a surface drinking water supply
the system is l in a nitrogen sensitive area(interim Wellhead Protection Area—M PA)or a mapped
Zone H of a p c water supply well
If you have answ d"`yes"to any question in Section E the system is considered a significant threat,or answered
"yes"in D above the large system has failed.The owner or operator of any large system considered a
signifi under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.3 a system owner should contact the appropriate regional office of the Department.
A
Page 5 of l l
OFFICIAL.INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:
Owner. W 6 k
Date of 1<nspeetion: 1 1�� —
Check if the following have been done You must indica*e`yes"or"no"as to each of the follom
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
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 not available note as NIA)
_jr
qr _ Was the facility or dwelling inspected for signs of sv'krage back up?
Was the site inspected for signs of break out?
— Were all system components,excluding the SAS,located on site?
— Were the septic tank manholes uncovered,owed,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
gmi�e—nance 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- f
_ Existing information For example,a plan at the Board of Health.
Y _ 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)(b7)]
5
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Page 6 of 1 I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOAM
PART C
SYSTEM INFORMATION
Property Address: -1 CankLOJ a+.�
— r
O
Owner:_ l Oi
Date of Inspection: LL _
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): Number of bedrooms(actual): c9
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):
Number of current residents: G)L
Does residence have a garbage grinder(yes or no): Lb
Is laundry on a separate sewage system(yes or no):,&0[if yes separate inspection required]
Laundry system inspected(yes or no):l
Seasonal use:(yes or no): W
Water meter readings,if available(last 2 years usage(gpd)): .
Sump pump(yes or no): ►L
Last date of occupancy:Mom[
COli MERCIAL/iNDU"STRLAL
Type of establishment:
Design flow(based on 310 CMR 15.203): _gpd
Basis of deZtank
(seatsfpersonsl , tc.):
Grease trapes ar no):Industrial wng tank t(yes or no):Non-sanitarisch aed to the Title 5 system(yes or no):Water mete ,' available:Last date oy/use:OTHER(d
GENERAL INFORMATION
Pumping Records
Source of information:
Was system pumped as part of the inspection(yes or no):_0
If yes,volume pumped:,_gallons—How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
( 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/Altcmative technology.Attach a copy of the current operation and maintenance contract(to be
ob_tained from system owner)
—Tight tank _Attach a copy of the DEP approval
Other(describe):
Approximate a&e of 11 compo is date—install (if known)and source of information:
Were sewage odors detected when arriving at the site(yes or no):
6
f
Page 7 of 1 I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: (so, � ��
Owner: LJ It,
Date of Inspection: I& 5iFQC-/
BUILDING SEWER(locate on site plan) .
n
Depth below grade:_
Materials of construction: cast iron 1144 PVC_other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK: a((locate on site plan)
Depth below grade: it
Material of construction: O_concrete_metal`fiberglass_polyethylene
_other(explain)
If tank is metal list age:_ is age confirmed by a Certificate of Compliance(yes or no):.(attach a copy of
certificate)
Dimensions: to Q(j S&
Sludge depth:,,a- d
U
Distance from top of sludge to bottom of outlet tee or baffle: _.
Scum thickness:_�_ - n
Distance from top of scum to top of outlet tee or baffle:$_ 0/
Distance from bottom of scum to botto f outlet tee jar baffle: j-
How were dimensions determined: , V1616;G�/
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet my M evidence of leakage,et .):
Vj -heem
'�-
Cet-
dT
GREASE TRAP:_(locate on site plan)
Depth below grade:_
Material of construction:_concrete_metal_fi b ass_polyethylene other
(explain):
DimensionZ
Scum thick
Distance frm to top outlet tee or baffle:
Distance frf sc bottom of outlet tee or baffle:
Date of lastComments recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related tt,evidence of leakage,etc.):
7
Page 8 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWACE IIISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 7
Owner•
Date of Inspection-
TIGHT or FOLDING TANK: (t:me
must be pumpeda of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete fiberglass_polyethylene other(explain):
Dimensions:
Capacity: gal
Design Flow: alIons/day
Alarm-present(yes or no):
Alarm level: Al in worldng order(yes or no):
Date of last pumping:
Comments(conditio of alarm and float switches,etc.):
DISTRIBUTION BOX: t (if present must be openea7(locate on site plan)
Depth of liquid level above outlet invert:
Comments(note ifbox is level artd distribution to outlets equal,any evidence of solids carryover,any evidence of
or gut of box,etc,)-�,ar 4AAU L / �CL cd c
PUMP CHAMBER: (locate on site plan)
Pumps in working order(yes or no):.
Alarms in worldng order(yes or n _
Comments(note condition of p chamber,condition of pumps and appurtenances,etc.):
Page 9 of i l
OFFICIAL. INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL.,SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address Cal /bC
Owner: U/01.,,0
Date of Inspection: ce
SOIL ABSORPTION SYSTEM(SAS) (locate on site plan,excavation not required)
If SAS not located explain why:
Type
leaching pits,number.L
Ieaching 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.):
6� r
4
CESSPOOLS: (cesspool must be pumped as p spection)(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 groundw inflow(yes or no):
Comments(note con ion 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 ondition of soil,signs of hydraulic failure,level of pondin„condition of vegetation,etc.):
9
Page 10 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPEC 1ION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address- 1K
a
Vj Aofj
Owner: V, O
Date of Inspection: I toy
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.
S
t!a
Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: get
Owner: WA<C�A M.16 " *tA
Date of Inspection: 6
STTE EXM
Slope
Surface water 10
Check cellar tleb
Shallow wells
Estimated depth to ground water 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:
Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
11
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