HomeMy WebLinkAbout0074 GALLEON WAY - Health 74 GALLEON WAY, MARSTONS MILLS
A= 098 050
i
TOWN OF BARNSTABLE 1�
LOCATIi7N � � AA6ha+V L At^A SEWAGE #
VILLAGE&t�k � ���`� ASSESSOR'S MAP&LOT
I INSTALLER'S NAME&PHONE NO.
SEPTIC-TANK CAPACITY
LEACHING FACILITY: (type) (size)
NO.OF BEDROOMS
BUILDERORO WNERR`
4eRIGITI'DATE: g 1 \�T —COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and 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 ��--�
z
A'A-
LOCATION SEWAGE PERMIT NO.
L -
ILLAGE
I N S T A LLER'S NAME i ADDRESS
BUILDER OR OWNER
�D,ATE PERMIT ISSUED
7
� DAT E COMPLIANCE ISSUED
0
l
Q�� ion
0
uS
4Y
No....---.. ..�.t: F��3 .r............
r-
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
vre�.........................OF.: irJiv ............................................
e�
' Applirtt#ion for Disposal Works Tonstrur#iun runtit
Application is hereby made for a Permit to Construct ()K) or Repair ( ) an Individual Sewage Disposal
System at:
...., �? ._..: .`� ' .................... ............------
...... � . �
Location•Address t
` O er Address
.............................................
Installer Address
Q Type of Building Size Lot.WZ/_.67K....Sq. feet
Dwelling—No. of Bedrooms......_...�............................Expansion Attic ( ) Garbage Grinder ( )
aOther—.Type of Building ............................ No. of persons..... Showers ( ) — Cafeteria ( )
Otherfixtures ......................................................--•------------------------------------------------------•---•----------....-----••-----------.
W Design Flow..........� ........................gallons per person per day. Total daily flow.._.......��10.....................gallons.
WSeptic Tank—Liquid capacity/,&?.._gallons Length Width.SS-........... Diameter-_-_--__-__-_- Depth.6._-
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....',/,R.f......sq. ft.
Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
z Other Distribution box ( ) Dosing tank (
'-' Percolation Test Results Performed ..........................•. Date..$4/�
W Test Pit No. 1------ ......minutes per inch Depth of Test Pit----Z2.......... Depth to ground water..!�_t!��_-- -.
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a ••••---•--•--•••-•---•-•-•---•................•--•-•-•-•••-•••......•-•-••-•••....---------•--•••••..........................................................
0 Description of Soil..NF ,A...-- r...... .......... � 'S,H' ---•---------------------------------•-------------------
W
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 ITIE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issu by the board of Yealth.
Signed-.. • •••••-- ............. ....•-•-�------ .. �! -
ate
Application Approved By-••••-•-•• �-4�,c__ - yl
Date
Application Disapproved for the following reasons:..............................................................................................................
--...-•---------------•--•-•------.........----------•---.....----.....-•---•------...--------......-------....•-••-••••----••••-••••-•••-••----•-•••--------------•--•----•.•--•-..------•••-----_._...
Date
Permit N Issued------...-• ...
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HE.QLTH
........ ......................OF rFJ �P
Appliratiun for Uiupuaul - lark9 Tonutrur#ion rrutit
�n,,,-
Application is hereby made for a Permit to Construct (;K),-,orepair ( ) an Individual Sewage Disposal
System at:
....a..flocatio.-Address....__..... s �......SS .................
�f Location-Address or Lot o
p�..._L. c::.'> '�✓/ /(l ................................... ....1�..?!...4%:..//1...II .!! -Kf .....
Address
----•-•---------------•----•-----•-------- ............................................. - ........... ...
Installer Address
UType of Building _ Size Lot. .`� .......Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
Other—a Type of Building�,
No. of persons....�-f............____._ Showers ( ) — Cafeteria ( )
d Other fixtures ............................................................
W
Design Flow.._......_�`'�..........................gallons per person per day. Total daily flow..........�J3.�..........•-.--......gallons.
WSeptic Tank—Liquid capacity/fir'?...gallons Length___/_�.�...... Widths`_...._..... Diameter................ Depth-•��-.•-.:�_..--.
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area-._.'Z _l_......sq. ft.
Seepage Pit No---------------_---- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( /)
✓ir/ G r� f r
a Percolation Test Results Performed by. -----------------------•-------------------•--......-•----....----- Date- ...._!-----------•-----•--------
Test Pit No. 1....�:•�.......mmutes per inch Depth of Test Pit... ..-..._... Depth to ground water._"la^.:t'......__.
f4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
-------•-•---------------------------------------------------------------------------------•---_---........................................
.................
of Soil_ ._._... ! ..... c.��er Si>,vt A,/„,
x • ..............................----•-----•-----------------•---------------------•--------••---••-------•--...----....----------
W
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'TTL: 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been iss by the board o"Ifeath,
t` /
..--... ..../ ......_..._.__.
Application Approved By.... --
Date
Application Disapproved for the following reasons----------------------------------------•--------...----•----------------------------------------------....-•--
--------------------------------------------------•-•-----•-------------•-•-••----•-•-------
Date
PermitNo......................................................... Issued_.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
,/(,.k. ....................... t r l�i. •
O F....!...... !�'1.... ............................................... ,.^'
CIrdif iratr of Toutplianrr
THIS IS TO�C ,RTIF�, Tha�the Individual Sewage Disposal System constructed ( ) or Repaired
by... ::: ........... :!' n't....................................................... .. ...------...----------•-......-------•-------........
�} Installer 1jf
has been installed in accordance with the provisions of TITLE: 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No,9 -__>'yZ,,,------------------ dated-...............................................
THE ISSUANC OF THIS CERTIFICATE SHALL NOT BE CONSTRUED A GUARANTEE THAT THE
SYSTEM WILL CTION SATISFACTORY.
DATE......S f•-0' .................................................... Inspector_..... := ..
THE COMMONWEALTH OF MASSACHUSETTS
--- BOARD OF; HEALTH
//j�c
-' .'".'..............®F.....J:. v�i(�.✓......................... -•--.................. o
FEE......' ............
�i111ru �tl u Q19ttu r iun rrutit ..
Permission is herebyranted---. ^� , �r�
g ••-•----••-•---•--••... ---------------------•--•-----••------------•--....------•--------------••...........
to Construct ( 0 or Repair ( ) an Individual Sewage Disposal System
at No...�d> 14 6/l
Street
as shown on the application for Disposal Works Construction Permit No..................... Dated..........................................
DATE...........................la-•=.r�/..I ..••
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
YOU.WISH TO OPEN A BUSINESS?
For Your Information: Business certificates (cost$30.00 for-4 years). A business certificate ONLY REGISTERS YOUR NAME in town (which
You must do by M.G.L. - it does not give you permission to operate.) Business Certificates are available at the Town Clerk's Office, 1" FL., 367,
Main Street, Hyannis, MA 02601 (Town Hall)
r 3tr? '�� pro DATE: Fill in please:
d Elf a APPLICANT'S YOUR NAME/S:_MR
BUSINESS YOUR HOME ADDRESS. 7 V &6_11l:
. £� • TELEPHONE # Home Telephone Number. S- /•
NAME',OF CORPORATION:
NAME OF NEW.BUSINESS TYPE OF.BUSINESS IS THIS.A HOME OCCUPATION` YES NOr
ADDRESS:OF'BUSINES9
MAP/PARCEL NUMBER_
(Assessing):.
When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of
Barnst0ble. This form is intended to assist you in obtaining the information you may need.: You MUST GO TO 200 Main St.,- (corner of Yarmouth
Rd. & Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in this town.
1. BUILDING COMMISSIONER'S OFFICE
This individual has been informed of any permit requirements that pertain to this type of business.
Authorized Signature*
COMMENTS:
2. BOARD OF HEALTH
This individual h ben in o e oft ger �ilreq,_�,reme_nts
that pertain to this type of business:
Authoriz ignature*
COMMENTS:
3. CONSUMER AFFAIRS (LICENSING AUTHORITY)
This individual has been informed of the licensing requirements that pertain to this type of business.
Authorized Signature*
COMMENTS:
YOU WISH TO OPEN A BUSINESS?
For Your Information: Business certificates (cost$30.00 for 4 years). A business certificate ONLY REGISTERS YOUR_NA ,E in.x,��C�which you
Q.
must do by M.G.L.-it does not give you permission to operate.) You must first obtain the necessary signatures 6) *jiist-i rr� �nH Main St., Hyannis.
Take the completed form to the Town Clerk's Office, 1st FI., 367 Main St., Hyannis, MA 02601 (Town Hall) and get the Busin s tificate that is
required by law. 2D09 FEB 23 AN,
'
DATE: Fill in please:_
APPLICANT'S YOUR NAME/S: t�If}U2�NE �E�/4�-�0 �--
BUSINESS YOUR HOME ADDRESS: -7-4 CAA
`
OS r-6_t2 i L _
" ? n, TELEPHONE # Home Telephone Number
- ZZ 7!�Z
NAME OF CORPORATION: 0A i S O 05`T V s LLB.
NAME OF NEW BUSINESS tit r ' TYPE OF BUSINESS ;t--eWe_1-1iy _SIGH! 5�3 LS
IS THIS A HOME OCCUPATION? %\ YES NO
ADDRESS OF BUSINESS VA /4MAP/PARCEL NUMBER (Assessing)
v
When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of
Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TC12->at. (corner of Yarmouth
Rd'. & Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in this town.
1. BUILDING COMMISSTCNER'S OFFICE
This individual h0s n i.RforqQ or an pe mit requirement hat pertain to this type of business. �l
Author' Signaturd*
COMMENTS J '' UN'
2. BOARD OF HEALTH
This individual ha be n infor Xhe=mit quirements that pertain to this type of business.
Authorize ignature*
COMMENTS:
3. CMSUMER AFFAIRS {LICENSING AUTHORITY)
This individual has been informed of the licensing requirements that pertain to this type of business.
Authorized Signature**
COMMENTS:
Town of Barnstable P#
Department of Regulatory Services
Public Health Division Date
MASS.
.639 200 Main,Street,Hyannis MA 02601
VOI '
lE0 AAI►'t� /�t
Date Scheduled Time Fee Pd.-j
Soil Suitability Assessment for Se age Disposal 6
�ZM �'� �-S•, Witnessed BTN
Performed By: l>" •� W Y:
LOCATION& GENERAL �-5 INFORMATION,,
Location Address —7)1 /''a'tp o o ti/ r Owner's Name be- le-P
15� Address j fs..v.-V
Assessor's Map/Parcel: 0 q�710 r o Engineer's Name O ev Ax P r t -to i,
NEW CONSTRUCTION _ REPAIR Telephone#
Land Use (rCJ (1" Slopes M 3 r Surface Stones �d
Distances from: Open Water Body 7��d ft Possible Wet Area 7�OG ft Drinking Water Wellft
Drainage Way /Uv ft Property Line ft Other ft
165. LUC aetbne-k
0
oil
0
` ,o
Q z w M� • t n W
° d �w � IN f
z .� �
I OUj
_ 4A lip
,{� Q
%
eg P� /
1 o..
,,►.R l 'j # 157.59
Parent material(geologic) ~ Depth to Bedrock
N Weeping from Pit FACe N
Depth to Groundwater. Standing Water in Hole: P $ ---�--��
Estimated Seasonal High Groundwater
DETERMINATION FOR SEASONAL HIGH WATER TABLE
Method Used:
Depth Observed standing in obs.hole: in. Depth to sa[I mtittl�s: [n•
Depth to weeping from side of obs.hole. in, Groundwater Adjustment ft.
Index Well# Reading Date: Index Well level --_ Adj,factor _ Adj.Groundwater Level,
PERCOLATION TESL' bate-JI"Ley Time !/ ^9
Observation (
Hole# Time at 4"
Depth of Pere Time at6"
Start Pre-soak Time @ It•13- Time(9"-6")
End Pre-soak f `74
Rate Min.flnch G Z
Site Suitability Assessment: Site Passed X Site-Failed: Additional Testing Needed(Y/N)
Original: Public Health Division Observation Hole Data To Be Completed on Back-----------
.. ***If percolation test is to be conducted within 100' of wetland,you must first notify the
Barnstable Conservation Division at least one(1)week prior to beginning.
Q:\SEPTICVERCFORM.DOC
DEEP.OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders.
Consistenc ravel
.Q L f
s- i6 Q, �S co rtir4
16 - 6 �
Gz /tt-t; IV,,d I it 6 ,v0 o
�V� 'f• ro`YG�
No 6:.
DEEP OBSERVATION HOLE LOG Hole# Z
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistency,%Gravel
�vytiY/Z /C,
C0,0"1
S -lW t; Z - t% Joy,. to 27 t 6/y do
VO G-L✓
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Gravel)
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders.
Consistency,
Flood Insurance Rate Map:
Above 500 year flood boundary No_ Yes
i
Within 500 year boundary No_ Yes
Within 100 year flood boundary No— Yes -
Depth of Naturally Occurring Pervious Material
Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the
area proposed for the soil absorption system? _ l'
If not,what is the depth of naturally occurring pervious material?
Certification
I certify that on p (date)I have passed the soil evaluator examination approved by the
Department of Environmental Protection and that the above analysis was performed by me consistent with .
the required tr ' in expertise a 4exienc eseribed in 310 CMR 15.017.
Signature Date
Q:\SEPTICVERCFORM.DOC
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET,BOSTON MA 02108 (617) 292.5500
Vv-aJJ M F.WELD TRUDY COKE
Governor Rf�` Sec:etar)
ARGEO PAUL CELLUCCI �9 DAVID Hz B.STRU
Lt.Governor
AR 2 1 1✓ty Commission:
�i T OWNO HAR
i'
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTIO
PART A `
CERTIFICATION
Property Address: �-a((///Qoi-& JUu Y // S /�-�"��S Address of Owner: -�to—
Date of Inspection: (If different)
Name of Inspector. M X`� A
Company Name, Address and Telephone Number: /vovi(�oC> c�_
eLVJW\2.a I.— ;�.o.�� at16y pcc_l
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:
Passes
_ Conditionally Passes
_ Needs Further Evaluation By the Local Approving Authority
_ Fail
Inspector's Signature: cl"� a
Date:
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this
inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspec:or 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 authorirt.
INSPECTION SUMMARY:
Check A, B, C, or D:
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.
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, 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 11/03/95) 1
w
�,� I`nn�,•I nn Rrctrlyd P.7c`•r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner:
Date of'Inspectwn:� .
B]SYSTEM CON DITIONALLY:PASSES (continued)
_ S wage back r breakout or high static water level observed in the distribu on box is due to broken or obstructed
pipe(s) dr'due to a broken, settled or uneven distribution box. The system ill pass inspection if(with approval of the
Board of Health):)broken
0t
""` pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
P The system required pumping more than four times a year due to roken 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
q FURTHER EVALUATION 15 REQUIRED BY THE BOARD OF HEALT
Conditions exist which require further evaluation by the Bo d 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 D RMINES THAT THE SYSTEM 15 NOT FUNCTIONING IN A MANNER
WHICH WILL PROTECT THE PUBLIC HEALTH AND AF—E Y AND THE ENVIRONMENT:
_ Cesspool or privy is within 50 feet of a s "ace water
Cesspool or privy is within 50 feet of a ordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD O HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DMERhtINES THAT
THE SYSTEM IS FUNCTIONING IN A MA ER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
The system has a septic tank d soil absorption system and is within 100 feet to a surface water supply or tributary to a
surface water supply.
_ The system has a septic to and soil absorption system and is within a Zone I of a public water supply well.
_ The system has a septic nk and soil absorption system and is within 50 feet of a private water supply well.
_ The system has a septi tank and soil absorption system and is less than 100 feet but 50 feet or more from a private watE
supply well, unless a ell water analysis for coliform bacteria and volatile organic compounds indicates that the we!I is
free from pollution om that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than
ppm.
3) OTHER
(revised 11/0 /45) 2
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: -74 6lletK
Owner: —t' 3),
r&%-la&A Z C.,' /
Date of Inspection.
03l/ 3 �g �-
D] SYSTEM FAILS:
I have determined that the system violates one or more of the following failure criteria as efined in 310 CMR 15.303. The basis
for this determination is identified below. The Board of Health should be contacted to etermine what will be necessary to correct
the failure.
Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or
cesspool.
Static liquid level in the distribution box above outlet invert due to n overloaded or clogged SAS or cesspool.
Liquid depth in cesspool is less than 6" below invert or availabl volume is less than 1/2 day flow.
Required pumping more than 4 times in the last year NOT d to clogged or obstructed pipe(s).
Number of times pumped_.
Any,portion of the Soil Absorption System, cesspool or pr' 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 of a public well.
Any portion of a cesspool or privy is within 50 fe t of a private water supply well.
Any portion of a cesspool or privy is less than 00 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the well as been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compou s, ammonia nitrogen and nitrate nitrogen.
Ej LARGE SYSTEM FAILS:
The following criteria apply to large systems n addition to the criteria above:
The system serves a facility with a design ow of 10,000 gpd or greater (large System) and the system is a significant threat to
public health and safety and the enviro ent because one or more of the following conditions exist:
the system is within 400 fe t of a surface drinking water supply
the system is within 20 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 suppl well)
The owner or operator of any such stem shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 a d 6.00. Please consult the local regional office of the Department for further information.
(revised 11/03/95) 3
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Y
PART B
CHECKLIST
00
Property Address: A( ,
Owner: _�1,r-f u k Z.o
Date of Inspection:
03// ���
Check if the following have been done:
Pumping information was requested of the owner, occupant, and 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 part of this inspection.
As built plans have been obtained and examined. Note if they are not available with N/A.
j�The facility or dwelling was inspected for signs of sewage back-up.
The system does not receive non-sanitary or industrial waste flow.
1�The site was inspected for signs of breakout.
All system components, excluding the Soil Absorption System, have been located on the site.
The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or
tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
The size and location of the Soil Absorption System on the site has been determined based on existing information or
approximated by non-intrusive methods.
AThe facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub-
Surface Disposal System.
(revised 11/03/95) 4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: .74 Gu lleo,� Wc,,l
Owner: —I--
Date of Inspection:./
�--
-FLOW CONDITIONS
RESIDENTIAL:
Design flow: 33(1� allons
Number of bedrooms:Q3
Number of current residents:0
Garbage grinder(yes or no):ty
Laundry connected to system (yes or no):
Seasonal use (yes or no):_&4,
Water meter readings, if available: Nii�
Last date of occupancy: MTV's ez%O'a—Ev
COMMERCIAUINDUSTRIAL:
Type of establishment:
II .ns/da
Deign flow ga o y
Grease trap present: (yes or no)_
Industrial Waste Holding Tank present: (yes or no)_
Non-sanitary waste discharged to the Title S system: (yes or no)_
Water meter readings, if available:
Last date of occupancy
OTHER: (Describe?
Last date of occupancy:
GENERAL INFORMATION
PUMPING RACORDS and source of information:
yS��v�- ih � e.�� >�e�i �� pt�u,.�o N• ra.t— ��c j w`�.
System pumped as part of inspection: (yes or no) 1�(Z)
If yes, volume pumped: ¢allons
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)
Other (explain)
APPROXIMATE AGE of all components, date installed (if known) and source of information: �� 1��-Z&
Sewage odors detected when arriving at the site: (yes or no) LU(�
(revised 11/03/95) $
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: �� �1QoK L{J�•c1_ ac.�S�o,.-S �`(S
Owner:
Date of Inspection
SEPTIC TANK:-*s
(locate on site plan)
Depth below grade: AV C'mvle—
Material of construction: concrete _metal _FRP —other(explain)
Dimensions: I000J!�It)
Sludge depth:)4 )
Distance from top of sludge to bottom of outlet tee or baffler,
Scum thickness: D "
Distance from top of scum to top of outlet tee or baffle: 10`�
Distance from bottom of scum to bottom of outlet tee or baffle:�t
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in re!ation to outlet invert, structural
integrity, evidence of leakage, etc.) 'N (� t^'
'Ct 1 Z3 V1r ,� s a
GREASE TRAP:�(�
(loate on site plan)
Depth be!ow grade:
Material of construction: _concrete _metal _FRP _ather(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:
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid leve! in re!ation to outlet invert, structural
integrity, evidence of leakage, etc.)
(revised 11/03/95) 6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 4- i�,- dec,k ���- / ccl r vs /--f—.1`S
Owner: i 'D►'LA- cat w --�
Date of Inspection:
TIGHT OR HOLDING TANK:��
(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _FRP —other(explain)
Dimensions:
Capacity: gallons
Design flow: gallons/day
Alarm level:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX:�4'��
(locate on site plan)
Depth of liquid level above outlet invert: %JS W',0010- TPN%/tJ�
Comments:
note if level and dist ution 's ual, evidence of solids carryover, evi ence of leakage into or out of box,�;,c.)
On
ja
ut o I
PUMP CHX,OER:_w 0
(locate on site plan)
Pumps in working order.(yes or no)
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
(revised 11/o3/9s) 7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION/(continued)
Property Address: �f C/�o v— ��Y c`��' ""�'`S `ffS '
Owner: —7— ^-
Date of Inspectio .
O 3(/ 7 j C7
SOIL ABSORPTION SYST M (SA
(locate on site plan, if possible; excav tion not required, but may be approximated by non-intrusive methods)
If not determined to be present, explain:
Type:
leaching pit, number: 1M.10
leaching chambers, number:_
leaching galleries, number:
leaching trenches, number,length:
leaching fields, number, dimensions:
overflow cesspool, number:
C mme-t:: (note condition of soil, signs of hydraulic failure, level of pondi , c dition of ve-etation,etc.)
1r,
CESSPOOLS: Uf;
(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert:
Depth of solids laver.
Depth of scum laver:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater:
inflow (cesspool must be pumped as part of inspection)
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY: t�C�
(locate on site plan)
Materials of construction: Dimensions:
Depth of solids:
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
(revised 11/03/95) 8
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFOO,RoMATION/ (continued)
Property Address:
Owner: 17 Jt• ���� /
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
z
is
?� 211G -33�
DEPTH TO GROUNDWATER
Depth to groundwater: iZO feet C
method of determination or approximation U,5. ci i Jcs��'S
(revised 11/03/95) 9
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