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Home My WebLink About0237 OLD MILL ROAD - HealthF7237 OLD MILL ,` MARSTON MILLS = i e/ TOWN OF BARNSTABLE LOCATION 237 O/s/ AZ YJ AW SEWAGE # 951' 3 3? VILLAGE e,%ar Vt4 � ��/s ASSESSOR'S MAP & LOT 4g Q/Z INSTALLER'S NAME & PHONE NO. �O�h �• ga It, SEPTIC TANK CAPACITY /DOD LEACHING FACILITY:(type) . /000 4 (size) Lje/O NO. OF BEDROOMS 3 PRI/IVATE WELL OR PUBLIC WATER BUILDER OR OWNER �i Gh q rp� i h d /�'+�► �� DATE PERMIT ISSUED: p � DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No q-cr Q- c - 9• E - sa .78 . A -� av .� -F 3 s, 6 8 PC4, 9'/ No..��......_ THE COMMONWEALTH OF MASSACHUSETTS APPROVED BOARD OF HEALTH ZZ7=: OWN OF BARNSTABLE � A11VEra—iFt7or Di ipwiu1 Works C ontitrnrtinn rnmit Application is hereby made for a Permit to Construct ( ) or Repair (V) an Individual Sewage Disposal System at: ,,�� / 11 of do Addre, p ,p or Lot No. �j /� �C�lvy !�i.s�fy.gY /_� L FIQ h�1 .. !!d Gj/�e?... Q260.. ................ ....•----• --.. .... n.....- ad „•„�`l& �Sv w�l., .,�� S1� � `sfv�sgGti Installer Address Type of Building Size Lot............................Sq. feet U ., Dwelling— No. of Bedrooms--------1?-------------------------------Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) a' Other fixtures ------------------------------- - - W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length---------------- Width................ Diameter._-..-._------- Depth................ x Disposal Trench—No. .................... Width.................... Total Length-------------------- Total leaching area-----_..............sq. ft. Seepage Pit No-------------_---.- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date------------------...................... Test Pit No. 1................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................ 44 Test Pit No. 2................minutes per inch Depth of Test Pit-_.._-.._._._____--- Depth to ground water........................ �..............-.............................................................. __ " :-----•--------------...._-------•----.........----••-•-- 0 Description of Soil------------------� ..._............_ .. ------••- ' ....--------------'---...--- •---•'-'-"-""--••---------•--•'------.............--- W V ............................................... ---'-'••-"'-------'•'•-•--'••'•-'•"-"----'-------'•--•'-------'----'-"--'----'-"-----"--...-------•"'-'--"•---'------'--'...............'--...... W ......................................................................................................................................................................................... gip,�.y V Nature of Repairs or Alterations—Ans er why applicable..._AAa14 r_.c._..2---Ce s S wv 1_'._. _.__..._ _..�....... ! .........................................Z.2 0.0----- �J ` e •-�N H-ll....... �(.. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the :. system in operation until a Certificate of Compliance s b n issued by the boar f health. Signed .............. .... ................... ......... .� ?O—�.� Dare Application Approved By - - ! /-.. ........................... .......... Dace Application Disapproved for the following reasons: ...................................... .. .......... ....................................................................... . ...................................................................... . . ............................. .................. ------ ------------------- 4`1ce Permit No. "�. .... Issued �'. `� ... .......... .............. ................ ........ ... ...... ..... Due* ace �.,.....��w..-pis,.•+..-:i... .-«. .,r•----.�..�.•.....,�._;..., -ti.,.......�._..-:s.r,,.....-....�.�-,.bb .�...,T✓s..a;w"'.. �.ra�. ,.ra.�..:.�.+..-.-.-sf:.....T...�y.. ,, .,... .w�.. -vu'v'��-�-4.�-u�w..`.;r 3 i�f No.•�........!�.. pGC. Fizz,, .....�� .- " THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH • X TOWN OF BARNSTABLE - ski (o a O �/ ri l ,��ltrtt#tit dux �t��.�n,��l �urk� Cn>agt�trurttun Frrmit 4 Application is hereby made for a Permit to Construct ( ) or Repair ((/) an Individual Sewage Disposal Svstem at: / , ou 47 232 0)c /YJ '// /� .5/ ......................--�--------------------------------------------------•----- `--...... . .............................................. �ofstio -Addre' or Lot No. Jam, �i K$ G,p �t(✓�/ ...............r �^ fHl G?!.. �n(/!_rL.Nr ._...�a �1--![./gh� ..9(/J------- / .....^ ` t�O�.n r Ad ress 1 �/ W .-1v`'h l�G� !v /sU GG��i, 'x , /ytii_S/d&. t /P1;/eS �� d�� ! ,., ............... -- ..... Installer Address UType of Building Size Lot_..........................Sq. feet .. Dwelling—No. of Bedrooms-__-_----.t___________________.-____-_-._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............................................gallons. WSeptic Tank—Liquid capacity............gallons Length---------------- Width_______________ Diameter................ Depth.............. Disposal Trench—No. .....:.............. Width-------------------- 'Total Length-------------------- Total leaching area.___._..............sq. ft. 3 Seepage Pit No--------__---____- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) . Dosing tank ( ) `" Percolation Test Results Performed by.......................................................................... Date........................................ ,.a Test Pit No. 1................minutes per Inch Depth of Test Pit.................... Depth to ground water L14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ P4 ....------•--------------------•-••---••-•-•-•......•••--•-•---------••••...--------------...................--------••••--•-••..........................----- Description of Soil `,h --•-------------•-•--------------------------------- V .....•---•------•-----••-•----------------•---•-•.....----•••--•••••-••••----...--•--•----•-••-•-----•••••-•------•--•-•-----••-----•-------. W -----•-••-••----------•--------------------------------------------••---•------------------••---•--•----.....................................................•--------------------------•............-- U Nature of Repairs or Alterations—Answer when applicable-__1&41.._t_-t. -_-2-.r?A5 47,9& < -------- - Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance as b n issued by the board of health. Signed .......... - .t� ................................................... ........................................ Dare .Application Approved BY ' .........::.... � 1 •........:_.............................. _� ..w�7-`-C� Application Disapproved for the following reasons: ..........................................- ................................... ..---------------- ........ ... ............................................................... Permit No. -. ` ..2.....:: -.. Issued ................�! ..... Dare THE COMMONWEALTH OF MASSACHUSE17S ,BOARD OF HEALTH t TOWN OF BARNSTABLE C&ez#ifira e of (1omyIiattce THIS IS TO CERTIFY, That t e Individual Sewage Disposal System constructed ( ) or Repaired ( v) by ........................ D.. !.?�d..... r. __._............ - ..-.... - - -- ��an ............................. at --------- --- ..< '....... ..... .....�... " ,f----------- has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. -....-_._... .............. .............. dated ............_......._---------------....- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE....-.......00.0._...04." ... .. ...... - ............... Inspect r, .r.-..... - THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE / No J/�--'... 0;? FEE.:........ ..... - �C` Permission is hereby granted....----� �" lS to Construct C ) or Repair (L-f an Indivirlu 1 ewa isposal y/s7l !�J Street as shown on the application for Disposal Works Construction Permitt`_. ..r��_ ated-----�J-.-:..=`� /. -�... -- ------------ �� oard of calth ---••--•-•-----•----_-•---~ DATE......'r�`------.��`.-- -------��•---................. FORM 36508 HOBBS&WARREN.INC..PUBLISHERS f COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET, BOSTON MA 02108 (617)292.5500 TRUDY COXE Secretary ARGEO PAUL CELLUCCI DAVID B. STRUHS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A /n� '' CERTIFICATION Property Address: 2-3-7 old M;11 rc0,Nl AOr"SM,•11S Name of Owner , CA. mot L�r��u r k//�� u Address of Owner: Date of Inspection: 9/ ��LL Name of Inspector:(Please Print) I am a DEP approved syste�m inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) Company Name: �e A /iA fi i . O l MaLng Address: _ r/s Telephone Number: _ �ZL-ys9 5- 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 Fails Inspectors Signature: Date: The System Inspector all submit a copy of this Inspection report to the pproving Authority(Board of Health or DEP)within thirty(30)days of completing this inspection. If the system Is a shared system or has a desig ow 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. NOTES AND COMMENTS g 10 1998Q y�rtyoF TAa�F vp revised 9/2/98 Page I of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) f�� Property Address: Old M,*II RC(„ Mq,sins M,'I L,MA Owner: R;"-kq(-d 1-4r�j/1ark Date of Inspection: Z_I Z—01 q INSPECTION SUMMARY: Check A, B, C, of A A. SYSTEM PASSES: I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure criteria not evaluated are indicated below. COMMENTS: B. SYSTEM CONDITIONALLY PASSES: Ar/7' 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 NO). Describe basis of determination In all instances. If"not determined",explain why not. The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)Indicating that the tank was Installed within twenty(20)years prior to the date of the inspection;or the septic tank,whether or not metal,Is cracked,structurally unsound,shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank Is replaced with a complying septic tank as approved by the Board of Health. Sewage backup or breakout or high static water level observed In the distribution box Is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). broken pipe(s)are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass Inspection if(with approval of the Board of Health): broken pipe(s)are replaced / obstruction is removed / revised 9/2/98 Page 2of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Z37 pid M;l� ilZd., Mars�ons M,'//s,MR Owner: i c�a�CJ� �,'ndfhc►r L,, Date of Inspection: C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: 11114 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 IN ACCORDANCE WITH 310 CMR 15.303(1)(b)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 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 W A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: 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 soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS 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 presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER revised 9/2/95 Page 3of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 7-3`7 Old M;i1 PA,, MdrS�dns fA;NS, MA Owner: (�;t_�.uCd L;ndnewt< Date of Inspection: D. SYSTEM FAILS: You indicate either"Yes" or"No" to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 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 into iacilityor 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 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 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. V Any portion of a cesspool or privy is within a Zone I 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" to each of the following: The following criteria apply to large systems in addition to the criteria above: 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 upgrade the system in accordance with 310 CMR 16.304(2). Please consult the local regional office of the Department for further information. revised 9/2/98 Page 4of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST a Property address: 2.37 Old M 11 (1d,�a r S tor"' M;Ns,M Owner: R;c_I.arJ 1_1*nJM01`44� Date of 4upection: Z-IZ-`t°1 Check if the following have been done:You must indicate either"Yes" or"No" as to each of the following: Ye; No /99f _/ _ Pumping information was provided by the wne , occupant,or Board of Health. V _- None of the system components have been pumped,for-at least two weeks and-the system has tieemreceivitMi ormal flow rates during that period. Large volumes of water have not been introduced Into the system recently or as part of this Inspection. As built plans have been obtained and examined. Note if they are not available with NIA. _ The facility or dwelling was inspected for signs of sewage back-up. _ The system does not receive non-sanitary or industrial waste flow. _ The site was inspected for signs of breakout. _ All system components,excluding the Soil Absorption System, have been located on the site. _ The septic tank manholes were uncovered,opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction,dimensions,depth of liquid,depth of sludge,depth of scum. / The size and location of the Soil Absorption System on the site has been determined based on: ✓ _ Existing information. For example, Plan at B.O.H. f_ 7- a p y _ Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) / 115.302(3)(b)) V . _ The facility owner(and occupants,if different from owner)were provided with information on the proper maintananceof SubSurface Disposal Systems. revised 9/2/98 Page Sof11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: z3l 0ICA M:II Rj.,Ma rsjon,y M,'lls, M A Owner: P c-kat cl L;ndocark Data of Inspection: q FLOW CONDITIONS RESIDENTIAL: Design flow: 330 g.p.d./bedroom. Number of bedrooms(design): Number of bedrooms(actual):_3 Total DESIGN flow Number of current residents-, Garbage grinder(yes or no):—.&f Laundry(separate system) (yes or no):NO; If yes,separate inspection required Laundry system inspected (yes or no) Seasonal use(yes or no):,!J�V Water meter readings,If available(last two year's usage(gpd): Ave rc15¢, sd Ob Sump Pump(yes or no):--&0 Last date of occupancy re5e"I'4X COMMERCIAL/INDUSTRIAL: J T establishment: Design flo d ( Based on 15.203) Basis of design flow Grease trap present:(yes or no_ Industrial Waste Holding Tank present:(yes )_ Non-sanitary waste discharged to the Title 5 s s or no)_ Water meter'readings,if available: Last date of occupancy: OTHER:ID e) La a of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: P✓�� rt�0�/vim, .,yr,QIle 4 SIC 4y79 System pumped as part of inspection:(yes or no) p If yes,volume pumped: gallons 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) IIA Technology etc.Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components,date installed Of known)and source of informati e� CH'� ✓i Sf4 �� /n . ��9� Sewage odors detected when arriving at the site:(yes or no) AV • revised 9/2/98 Page 6of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) j Property address: 2 37 Old Mal l Rd., Mck r5lons M"I Owner: R C-kQrd Lfndrr,arb- Date of Inspection: Z�(Z_99 BUDDING SEWER: (Locate on site plan) Depth below grade:~a Material of construction:_cast iron ✓40 PVC_other(explain) Distance from private water supply well or suction line Diameter Comments:(condition of joints,venting, evidence of leakage,etc.) SEPTIC TANK: (locate or+site plan) Depth below grade: Material of construction:concrete_metal_Fiberglass _Polyethylene_other(explain) If tank is metal,list age_ Is.age confirmed by Certificate of Compliance t' (Yes/No) y�� Dimensions: 119Q0eya� y 6 1� X PP Sludge death: ^-a2 Distance from top of sludge to bottom of outlet tea or baffle: Scum thickness: — 4 Distance from top of scum to top of outlet tee or baffler_ Distance from•bottom of scum to bottom of outlet tee or baffle: /`1 How dimensions were determined: /Yl�G��✓ 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.) 7iH a00041 aK&Crf fa 6� rfan6//a✓r :ma`s C{�a/kr�t/ GREASE TRAP• Won site plan) Depth bolo rade:_ ' Materiel of cons lion:_concrete_metal_Fiberglass _Polyethylene_other(explain) Dimensions: Scum ehickness: Distance from top of scum to,top of o tee or baffle: Distance from bottom of scum to bottom of at tee or e: Date of last pumping: Comments: (recommendation for pum ,condition of inlet and outlet tees or be depth of liquid level in relation to outlet Invert,structural integrity, evidence of leakage e7of11 revised 9/2/98 Pag f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) :Property Address: �-37 Oid M��I Rd Mars �vn� M 'Ils, MA Owner: R. c�kafd Date of Inspection: 1Z qck TIGHT HOLDING TANK: (Tank must be pumped prior to, or at time of, inspection) ilocate on si Ian) Deptt below grade:_ Material of construction:_co metal_Fiberglass_Polyethylene_other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm present Alarm level: Alarm in worki rder:Yes_ No_ C+ate of previous pumping: Comments: (condition of inlet t , condition of alarm and float switches,etc.) DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert: Comments: (note.if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box, etc.) ,( 1,✓Pl- 3 helm, ;rode PUMP CHAMBER l Pumps in working order:(Yes or No,) Alarms in working order(Yes or No} Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) i revised 9/2/98 Page 9of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Pr Address: 3 o 1cl ►v�:it Rol, Mars togs Property Z � Owner: R;c kard L I'l drnar(, Date of Inspection: 2_17— qal SOIL ABSORPTION SYSTEM(SAS): v' (locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods) If not located,explain: Type: leaching pits,number:1 leaching chambers,number:= leaching galleries,number:_ leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number:= Alternative system: Name of Technology: Comments: (note:condition of soil,signs of hydraulic failure,level of ponding, damp soil,condit'on of vegetation, etc.) Le-, P Q, r P CESSPOOLS:_ I ocate on site plan) Numbe configuration: Depth-.top of 11 ' o inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow (cesspool must be pumped as part o action) Comments: (note cond'' of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.) Poca on site plan) Materials of con on: Dimensions: Depth of solids: Comments: (note condition of soil,signs of hydraulic failure,level of p , c ion of vegetation, etc.) revised 9/2/98 Page 9of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(corrtimed) ® Property Address: 2.37 Old Rd-, MoiCS6ns M�'IIS� MA Owner: RiLkq(C�. L:f%d�(ram Data of:rupection: Z- ►7- SKETCH OF SEWAGE DISPOSAL SYSTEM: Include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes into house) A z. CA A ell revised 9/2/98 Page 10of11 J SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: VS7 Old M II Rd.i Ma rS�On S rod 11s, M A Owner: R l'c kard L nd ww,rl.. Date of Inspection: 2,-IZ-9q NRCS Report name Soil Type_ Typical depth to groundwater USGS Date website visited Observation .Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to Groundwater Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observed Site(Abutting property,observation hole, basement sump etc.) Determined from local conditions ✓ Checked with local Board of health Checked FEMA Maps Checked pumping records Checked local excavators,installers Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) CIs r4 72 ' '551. y� o9011 aY ugrer revised 9/2/98 Page 11 of 11