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Home My WebLink About1776 RACE LANE - Health 1776. RACE LANE MARSTONS MILLS A ! 048 002 001 E � LOCATION �� 7� S GE PERMIT N0. / VILLAGE A & B` CESSPOOL'SE RVI CE 128 BISHOPS TERRACE, HYANNIS, MA 02601 BUILDER" -OR OWNER y - DATE PERMIT ISSUED. , DATE COMPLIANCE ISSUED e � 1 n� � Q a e 6b , n� LA x TOWN OF BARNSTABLE LOCATION 1776 vim, �_, SEWAGE # � A VILLAGE�-o }�'{- ASSESSOR'S MAP , i LOT A r INSTALLERS NAME PHONE NO.c� yt p- 1CQ `�w SEPTIC TANK CAPACITY lbo o LEACHING FACILITYAtype) �i (size) L000 �. NO. OF BEDROOMS PRIVATE WELL OR-PIBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No � Ce Le� "� 4 1rL_/1 _L �- F THE COMMONWEALTH OF MASSACHUSETTS J� BOAR® OF HEALTH TOWN OF BARNSTABLE Apphrntion for UWpaiiai Marko Towitrnrtiun runfit Application is here made for a Permit to Construct ( ) or Repair (//) an Individual Sewage Disposal System at: .... --....---•--••--••• ••---....................•---••-•.........---•-••••••••--------•--.................•-- - LocatiL Add ess c_ f ....t..I., O ` or Lot Igo. ._.. ..........._ -•- .........• ---- �. C 4 - - --- ' Owner •...........Ad res Installer Address Type of Building m Size Lot............................Sq. feet U Dwelling—No. of Bedrooms......... ------------------------..Expansi Attic ( ) Garbage Grinder ( ) '� Other—T e of Building No. of ersons.... Showers a YP g P ( ) — Cafeteria ( ) dOther 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........................................ 0 Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ rs, Test Pit No. 2................minutes per inch Depth of Test Pit---:................ Depth to ground water........................ W' ........................ 0 Description of soil-------- ------ - ------------ (�:.. V "-----------------------------•---- -•- W U Nature of Repairs or Alterations—Answer when applicable__ _____TF -------------V, ................... 1-g Agreement: J .._....•-- The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Envir mental Code—The undersigned further agrees not to place the system in operation until a Certificate of Com li nce has been i su d by the board of health. Signed ..... . W.... v .................. --�r-..... ��. Date Application Approved By . ......---- t ---- Dace Application Disapproved for the following reasons- ----------------------- - ------ -------------------------------------------------------........... .................... ..................................... --------. ---------------------------...-------------------------------- -------------------------- ------.------------------------........ -- ----------- -------------------................ Dace Permit No. ...r�-� - -7 - ....... Issued ---- .�-.---ry .. — Dare No.--------............. Fim' n, THE COMMONWEALTH OF MASSACHUSETTS ` BOARD OF HEALTH TOWN OF BARNSTABLE Appliration for Disposal Works Tonufrudiott Errant Application is here . made for a Permit to Construct ( ) or Repair (1,o an Individual Sewage Disposal System at: .......LaKJ-C T7 (o \ (� .Locatiyn Add ess cJ 11 or Lot Igo. ....... -... .... --.. ._.. - . - Addre -- a Ownet CC,.,4_AAt — �Installer YY� c Address Type of Building Size Lot--------------------------Sq. feet V Dwelling—No. of Bedrooms--------,�_.�_3--------------------------Expansio Attic ( ) Garbage Grinder ( ) aa Other—T e of Building No. of persons-- Showers —Type g = P ( ) — Cafeteria ( ) dOther 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. 3 Seepage Pit No--------------------- Diameter-------------------- Depth below inlet-------------------- Total leaching area------------------sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by-------------------------------------------------------------------------- Date---------------------------------------- Test Pit No. 1----------------minutesperinch Depth of Test Pit-------------------- Depth to ground water------------------------ P4 Test Pit No. 2----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water-_______-_----------_--_ x - - { - D Description of Soil---- ..,.. .. ----. ---------------- -----— - --- - ------- ----- --- ---- -- - - - ------ ---- -- - v � ,�• �} ---------------------------- - W -----------------------------------=------------------------- -------------------------------------------------------------------------------------------------------------------------------------- V Nature of Repairs or Alterations—Answer when applicable_____________ ________ } QL;+�------------l -'w3 �-� �. ------!^ 1 = ------------------------------------------------------- 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 CoinAince has been issuivd by the board of health. Signed t—_----------- ------- - ---- Dam ApplicationApproved By -------------------` J- lk.,r -� ----------------------------------------------------------------------- 3i `d 2 Dte Application Disapproved for the following reasons- ---------------------------------------------------------------------------------------------------------------------------------------- --------------------------------------------------q------------------------------------------------------------------------------------------------------------------------------------------------------------ ---------------------------------------- Permit No. --------�J- � I ^it Date _-------------------------- Issued -----------7 THE COMMONWEALTH OF MASSACHUSE17S BOARD OF HEALTH TOWN OF BARNSTABLE (ter#ifiade of 01omplianre T�.-JS IS TO CCERTIFY, That the Individual Sev(age Disposal System constructed ( ) or Repaired ( � by---------- : - -_-'t-�` ' 1`<-c,.-� �a LS. --- - ------------------------------------ -------------------------------------------------------------------------------------------------------------------------------- ------- --- Installer at ----------------------M y '- x t - �--5 has been installed in accordance with the provisions of TITLE 5 o The State Environmental Code as described in the application for Disposal Works Construction Permit No. ........ �__.37:�---------- dated -_-___._-__--_----_---------------______---- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE------------------ -` - ---------- ------------------------------ Inspector ------------------ ------------------------------------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Fim Disposal urku unutrttrt- n Frrutit` f Permission is hereby granted---------------- _-- -Cc v' ---------------------____-- --------------------------------------------------------------------- to Construct ( ) or��epid (l.��a �i id al Se�ageeDis Disposal System atNo. - ------------ --^'-�-'=--- - = ------------------------------------- Street c, as shown on the application for Disposal Works Construction Permit No. -379- Dated______________________ n (� ------------- ` 7 V Board of Health DATE------ ---- ------------------------------------------------ FORM 36508 HOBBS Q WARREN.INC..PUBLISHERS CERTIFICATE OF ANALYSIS Page: 1 j Barnstable County Health Laboratory \yssF��yct�l Report Prepared For: Report Dated: 2/1/2008 Alan Hebditch Order No.: G0844968 11 Old Fields Road Sandwich, MA 02563 Laboratory ID#: 0844968-01 Description: Water-Drinking Water Sample#: Sampling Location 1776 Race-LnTMar ons mills;MA�'� Collected: 1/30/2008 Collected by: A.Hebditch Map 048 Parcel 002 Received: 1/30/2008 Routine ITEM RESULT UNITS RL MCL Method# Tested Nitrate as Nitrogen 3.9 mg/L 0.10 10 EPA 300.0 1/30/2008 Copper 0.19 mg/L 0.10 1.3 SM 311113 1/30/2008 Iron ND mg/L 0.10 0.3 SM 3111B 1/30/2008 Sodium 25 mg/L 1.0 20 SM 311113 1/30/2008 Total Coliform Present P/A 0 0 SM9223 1/30/2008 Conductance 170 umohs/cm 2.0 EPA 120.1 1/30/2008 pH 6.7 pH-units 0 SM 4500 H-B 1/30/2008 The recommended maximum contamination level for drinking water exceeded due to Coliform Bacteria and Sodium. Those on a low sodium diet may wish to consult a physician.Retesting is recommender!. 1 Approved By• irector) 4 n 9 rn ra �j 1 UM Gi. c a rn �1 :a 0 ND=None Detected RL = Reporting Limit MCL=Maximum Contaminant Level Superior Court House, PO.Box 427, Barnstable, MA 02630 Ph: 508-375-6605 No.-----__� =-�"�-- BOARD OF HEALTH TOWN OF BARN STAB L 0X . 2 PABCB.wa �-3 Applitat ion for Melt Con5tructioni3ermit Application is hereby made for a permit to Construct ( ), Alter ( ), or Repair ( man individual Well at: Q f Location — Address Assessors Map and Parcel / 4 Owner Address Installer — Driller Address Type of Building Dwelling + �'----------- -- Other - Type of Building------------ No. of Persons------------ --——__ Type of Well 4 � — — Capacity--------------- Purpose of Well-,Q o+.cc7�ic_ Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation — The undersigned further agrees not to place the well in operation until a Certificate of Compliance has been issued by the Board of Health. Signed — / date Application Approved date Application Disapproved for the following reasons: ------------ -------- ---- - — --- -------------- date ---- Permit No. ��"~ — Issued— date BOARD OF HEALTH TOWN OF BARNSTABLE C ertif irate Of Compliance THIS IS TO CERTIFY, That the Individual Well Constructed ( ), Altered ( ), or Repaired by— — --— ——-—— -- — - Installer at 1774 teece has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation as described in the application for Well Construction Permit N =959 ��=��d&;U- Zug THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE Inspector--- ---------- — ------ r t Fee--A<, BOARD OF HEALTH TOWN OF BARNSTABLE 1 Ofpplicat ion-for Vell Con5tru ton Permit Application is hereby made for a peimit to Construct ( ), Alter ( ), or Repair ( k-ran individual Well at: Location — Address I A sors Map and Parcel NPtjd �1`C4 4 GGc ow( AAA Owner l� Address ff - Installer — Driller ` l Address Type of Building Dwelling L Other - Type of Building g--__—_—______ _t.AI er ons------ --- Type of Well p y 4 - P C —__-----_---- Ca acit �Purpose of of Well- -4 n�rf tic_ Agreement: The undersigned agrees to sln tall,the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Hea t,_�Or ::ate Well Protection Regulation - The undersigned further agrees not to place the well in operation until a Certificate of Compliance has been issued by the Board of Health. o Application Approved ----- L�� •'- �� J date Application isapproved for the following reasons: ------- ______—_—_— _ date ---- - Permit No.- 6`�� — Issued-- =---�-C -� Gate BOARD OF HEALTH TOWN OF BARNSTABLE Certificate Of Compliance THIS IS TO CERTIFY, That the Individual Well Constructed( ), Altered ( ), or Repaired (� by-- ��Sc c�.�,.,��-- ------ -----——----- -- — - -- Installer at- has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation as described in the application for Well Construction Permit d THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE--- - — Inspector—__---- -- -----------—-- BOARD OF HEALTH TOWN OF BARNSTABLE Ivell Con5truct ion Permit No. '�- 1�L�J Fee- rG� Permission is hereby granted to Construct ( ), Alter ( ), or Repair (4-j an Individual Well at: No. — - __ d_ n`N Street as shown on the application for a Well Construction Permit No. �r Gj�I � -- Dated--�! ' �06 --------------------- Board of Health DATE ~� ,W it p` -\ CO I IO?vM E.4 OF`MASSAGHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFiUR:S. d DEPARTMENT-OF ENVIRONMENTAL PROTECTION J TITLE 5 OFFICIAL INSPECTION.FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFA,CE SEWAGE DISPOSAL SYSTEM FORM. PART A CERTIFI CATI ON Property Address: 77( ,12,t,; Owner's Name, y _�a Owner's Address Date of Inspection: A:� � Name of Inspect• please - Company Name: Mailina.Address : .` r . Telephone Number: 150 "7—,7, ) U0 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the infornation reported below is ttrLe, accurate and complete as of.the time of the inspection. The inspection was performed based on my training and experience.in the proper function ard'maintenance of on:site sewage disposal systems.. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(3:10 CMR 15.000). The system, Passes Conditionally Passes Need Further Evaluation by the Local.Approving'Authority. f Fails -Inspector's SiEuatus e Date:. 7 01�D r 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 Q'd or g-eater,the inspector and tiie 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.. . Ae T '6 - otes and Comments a � ��_��'-��•�. � h N - This report only conditions at the time of inspection.and under the conditions?of use at that o y p . 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 E/15/2000 page 1. t f Page 2 of 11 OFFICIAL INSPECTION FORM,-NOT FOR VOI.UNIARY ASSESSMENTS SUBSURFACE SEWAGE'DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owners Date of, spection: Inspection Summary: Check- A,B,C,D or E/AL.WAYS completi.all of Section D A. System Passes: I have not found an information which.indicates t a .Y h t am ofthe failure criteria described in 310:CMR 15.303 or in 310 CIviR 15.304 exist. Any failure criteria.not evaluated are'indicated below: r Comments: B. System Conditionally Passes: One or.more system con,ponents.as described in the`Conditional Pass"section need to be replaced or repaired.The system, upon completion of the replacement or repair;.as approved by the Board of Health;will pass. Answer yes,no:or not determined(Y,N, ND)in the for the following statements. 1f"not determined"please explain. The septic;tank is metal and over 2.0 years old, or the septic tank(whether metal or not)is structurally unsound,exhibits substantial.infiltration or enfiltration or.tank failure is imminent:System will pass inspection-if the existing tank is replaced with a complying septictanlc.as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. . ND explain: Observation.ofsewage:backup or.break out or High static.water level in the distribution box due to broken or .obstructed pipe(s)or due to a.broken, settled or uneven distribution box. System will pass inspection if(with. approval of Board.of Health): broken pipe(s)are replaced obstruction is.rernoved distribution box is leveled or replaced , ND explain: The system required pumping more than.4 times a year due to broken or obstructed pipe(s).The system will pass.inspection if(with.approval of the Board of Health).: broken p.ipe(s),are replaced obstruction Js removed' ND explain: J Page 3 of 11 OFFICIAL 11N TION FAR -.NOT FOR VOL,ITNTARY ASSESSMENTS SUBSTJR��AE SEA GE DISPOSAII SYSTEM`INSPECTION FORM PART.A CERTIFICATION,(continued) Property Address: . ?W -'Alt;;(y Xaa Owner , e-W Y/ Date of I s'pection ,r a 1;2.v ""i , •fit` �" C. Further Evaluation is Required by the Board:of Health: Conditions exist which require fiu Sher evaluation by the Board of Health in order to determine if the system is failing to protect psblic health, safety or the environment. 1. System will pass unless Board of.Health determines in accordance with 310 CMR 15'303(1)(b) that the system is not functioning in a manner which will protect public health;safety and:the environment: Cesspoo or privy is within 50 feet of a"surface water Cesspoo_or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. Svs.tem:willfail unless the.Board of Health{and Public.Water Supplier,if any):determines that the system is functioning in a_manner that.protects the public health,safety and environment: . The system has aseptic tank and.soil absorption system (SAS)_and.the SAS is:within 100`feet of a. surface water supply or tributary to a surface watensupply: The system has a septic tank and SAS and the SAS is within a Zone 1 of a'public water supply. The system has a septic tank.and SAS and the SAS is within 50 feet of a private.water supply well_ _ The system.has a septic tank and SAS and the SAS is less than 100 feet but 50 feet ormore from a private water supply well"*. Method used to determine distance "*This system passes if the well water analysis;performed at a DEP certified laboratory, for coliform bacteria and v:)Iatile organic compounds indicates that the well is.free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal.to or less than 5 ppm,provided thatno other failure critellia are triggered. A copy ofthe analysis:must be attached to this form. Other: .3. Paae 4 of.11 OFFICI All INSPECTION FORM—N OTFOR VOLUNT..A RYAS SESSMEN TS SUBSURFACESEVAGEDISPOSAL �:� STE1� INSPECTION FORM PART A CERTIFICATION(continued) Property.Addressr v %tom ,t e - -Owner: �P' 9 Date of Inspection:l dt_", 'a jo, D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each.of the.following for all_inspections: Yes NO L•' Backup of sewage into;facility or system component due to overloaded-or cio2Qed SAS o ..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 %day flow f�. 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. _ Anyportion of cesspool or privy is within I00•feet of 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. 4 Any portion of.a cesspool or privy is within.50 feet of'a:private wat.er supplyrwell ' Any portion of.a cesspool or privyis•less'than 100 feet but a eaterthan.50 feet:from a private water supply well with no acceptable water quali-yanalysis..[This system passes if the well water analysis, performed at..a.DEP certified laboratory-,for colifo rm.bacteria andivolatile organic compounds indicates that the.weil is free from pollution from that.facility and the:presence of ammonia nitrogen and. nitrate nitrogen,is.equal:to or less than 5 ppm,:pravided that no.other failure criteria lare 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 ')10 CIMR 15:303,therefore the system.fails. The system ownershould contact the Board of Hearth to determine what will be necessary to correci the failure. E. Large.S'yste:ms: To be considered a large system the system must serve':a.facility`with a design flow of 10,000 gpd to 1.5,000 gpd You must indicate either"yes" or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no _ the system is within 400 feet of a.surface drinking water supoly 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 If you have answered"yes"to any question in Section E the system is considered'a significant threat,.or answered "yes"in Section D above the.large system has failed.The owner or operator of any large system considered a significant threatunder Section E or failed under Section D shall upgrade the system in accordance with 3.10 CMR 15.304.The system owner should contact the appropriate regional office of the Department. ,4 . Page 5 of I i OFFICIAL:.INSPECTION:FQRii�rl—NOT FOR.VOLIJ-NTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL;SYSTEM. INSPECTION FORA PART B CHECKLIST Property Address: J.7 ,.�,.Wl 77 ,,✓ Owner• .� .�'�"� .�._� .q,-�:�-�' Date o;Inspection: a. . .." a Check if the following have-been done.You must indicate`yes"or"no" as to each of the following: Yes. o Pumpinz information was.provided by the:owner,•occupant,or Board of Health 1✓ Were any of the system components pumped out in the previous two weeks.? ' ems' Has the system received normal flows in the previous two week period? ZHave 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.N/A) 9 _ Was the-facility or dwelling inspected for signs of sewage back up (. _ Was the site inspected for signs of break out? r _ Were all system components, excluding the SAS;,located.on site Were the septic tank manholes uncovered; opened; and.the interior of the tank inspected ;or the condition of/�thz baffles or tees, material of construction, dimensions, depth of Iiquid,.depth of sludge and depth of sctitn Was the facility owner(and occupants if different from owner)provided with information.on the proper maintenance of subsurface sewage disposal systems ? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: Yes//no Existing information. For example, a plan at the Board of Health. a Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)1 Page 6 of I 1 OFFICIAL INSPECTION FORM NOT FOR:VOLUNTARY ASSESSMENTS = SUBSURFACE-SEWAGE DISPOSAL:SYSTEM INSPECTION FORM PART SYSTEM-TNF.ORMATIOt I Property Add:'ress: !° ✓� �? Owner: IA Date:of I petition: t' j, i FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design)::.. Number of bedrooms(actuaI).: DESIGN flow based on`3 10.CMR 15.203 (for example- 1'1:0:gpd x T of bedrooms): Number of current residents: "�C Does residence have a garbage grinder(yes or no):,,.Al eI Is laundry on a!separate sewage system (y s or no): jif yes separate inspection required] Laundry system inspected(yes.or no): Seasonal use (yes or no): Water meter readings, if available(last 2 years usage(gpd)): b Sump pump (yes or no): . �� s L.�'��✓ %' �� u �'J„ Last date of occupancy:( e ''�$� .�'l; � / � ,. C OMME RCIAL/IND USTRIAL./ .01 Type of establishment:; Design flow (based.on 310 CMR I5.203):: gpd Basis of"desigrr flow(seats/persons/sq'ft,etc.): Grease.trap present(yes or.no);_ Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5'system(yes or r_o)`:_ Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Recprds Source of information: Was system pumped as pan of the inspection'( es or no): �1 W 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/Alternative technology.Attach a copy of tht current operation and maintenance contract(to be obtained from system owner) . _Tiaht tank; _Attach a copy of the DEP approval Other(describe): +� ,' ✓' '� ,! i.� y 1 -. s•) y J{ _./ /✓��A � ; Iljbwfin�C.'^^i. I i..bid proximate ace of 4l1 components, date installed(if kn wn)and source of information:. i Were sewage odors,detected when arriving at the site(.yes or no'. _ .6 Page 7 of 11 OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL'SYSTEM INSPECTION FORM PART C SYSTEM.INEORMATION(continued) Property Address: a_� l✓, � L ,. Owner: Date bf. spectionAI BUILDING SEWER(locate on site plan)WM Depth below grade: Materials of construction: cast iron 40 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) 4 Depth below grade: � ' r Material of construction.Leo rete_metal_fiberglass Polyethylene _ot`ier(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach.a copy of certificate) , r Dimensions: o , ' Sludge depth: jd Distance from top of sludge to bottom ofoutlet tee or.baffle: 27 . Scum thickness: Distance from top of scum to top of outlet tee or baffle`. Z ;1 Distance from bottom of scum to bottom of outlet tee or baffle: How were .dimensions determined:xabz .4 ,011141 Comments (on.pumping recommendations,Anlet and outlet tee or baffle condition, structural integrity,liquid levels as related to outlet invert, evidence,of leakac, etc.): , (4677 �� Cr�� 'f.��l.�i�°'�''y �'�/�'A, ,,r��'�`�"'9 ��:5 'L4:e?Ki+�" �,�d�= C/�®•�9�' �' ��laG.,��° � GREASE TRAP)) _,,(locate on site plan) * ?,�� ', v )—& ` /" �c,r� ✓ - Depth below grade:_ Material or-construction:_concrete_metal_fiberglass polyethylene_other (explain):. Dimensions-, Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last.pLmping Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leak..age, etc.): 7 Page 8 of 1.1 OFFICIAL.INSPECTION FORM-NOT FOE:-OLUINTARY'ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C.. SYSTEM INFORM,-TION(continued) Property Address: Owner: // Date of InWection: s� _ �d TIGHT or HOLDING TANK: I(tank must be pumped at time ofinspection)(locate.on.site plan) Depth.below grade: Material of construction: concrete metal fiberglass polyethylene other(explain)-. Dimensions: Capacity: gallons Design Flow:: gallons/day' Alarm present.(yes or no):. Alarm level: Alarm in working order(yes.or no): Date of last pumping: Comments(condition of alarm and float switches, etc.): DISTRIBUTION.BOX:A(if present must be opened)(locate on site.plan) Depth of liquid level above outlet invert:: Comments (note if box is Ievel and distribution to outlets equa,.any evidence of solids carryover; any evidence of leakage into or out of box, etc.): I PUMP CHAMBER (locate on site.plan): 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.): Page 9 of 11 OFFICIAL INSPECTION FORM.—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL,SYSTEM INSPECTION FORM PART C SYSTEM.INFORMATION(continued) Property Address: / 7 � .a zP Owner' 6_4zJ , '- fSX_v.A �� Date of Vspection:(- t'01 SOIL ABSORPTION SYSTEM (SAS): i./ (locate on site plan, excavation not required) If SAS'not located explain why: TYP? leaching.pits,number: -leaching chambers,number: leaching.aalleries, number: leaching trenches,number: length: leaching Yields,-number, dimensions: overflow cesspool;number: __nnovativefalternati.ve system- Type/naive of technology: Comments (note condition of soil. signs of hydraulic failure, level of pondin2.dampQl, condition of vegetation; etc ' CESSPOOLS: ��7)(cesspool must be pumped as part of inspection)(locate on site plan) Number and con izuration: Depth:—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of.groundwater inflow (yes or no): - Cor_:ments (note condition of soil; signs of hydraulic failure, level of ponding, condition of vegetation, etc:): PRIVY: )��.,9'(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.)- A 9 - Page 10 of 1.I OFFICIAL INSPECTION-FORM.7,NOT FOR VOLIJTNTAR.Y ASSESSNIENT.S SUBSURFACE SEWAGE DISPOSAL SYSTENLINSPECTION.FORM PART- . SYSTEM INFORMATION(continued) Property Address: :. :r'� 54 Owner. 9 1',0!'V1 , Date of I pection � - en SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch ofthe.sewaQe disposal system includina ties to at Ieast two permanent reference landmarks or benchmarks.Locate all wells within 100"feet:Locate'-where public water-supply enters the buildin'g. Ic t re—rk Lo U� L✓� 1 J �Jtu LU, IO L Pare 11 of I 1 OFFICIAL INSPECTION FORM =NOT FOR VOLUNTARY ASSESSMENTS SUBSI7RFACE SEWAGE DISPOSAL SYSTEM INSPECTION:FORM PART C SYSTEM INFORMATION (continued) p a��rFa Pro e Address: Owner:211-14J`'d . ? ' ti Date of bn°spection L a,�, �t SITE EXAM Slope Surface water Check cellar Shallow wells Estimated.depth to ground water. fee, Please indicate(check):all methods used to determine the high ground water elevation: Obtained from systzm design plans on record-If checked, date oPdesign 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: ale'? C" '� � ,� l E r 11 Permit Number: Date: Completed by: dv HIGH GROUND-WATER LEVEL COMPUTATION Site Location: � f '. G ' 4/1 �- "'l t d � Lot No. Owner: k• !�' .I" Address: -.-- - - Contractor: Address: gl,4Jf" s Notes: STEP 1 Measure depth to water table tonearest 1/10 ft. .................................................:............................. .Date month/day/year. STEP 2 Using Water-Level Range Zone._ and Index'Well Map locate site.and determine OA .Appropriate-index well ...:.................................... B Water level range zone ...... STEP 3 Using monthly report",Current Water:Resources Conditions determine current depth.to ,a, }�.�d✓ 'wate.r:.level.foc..:m'dex.wela �J T............ month/year STEP 4 Using Table of-'Water4evel-Adjustments for index::well-,(ST-E.P.:2A), current depth to water-level for:index-well (STEP 3), _.. and water level zone (STEP 2B) determine water-level adjustment .......................................................................................... STEP 5 Estimate depth.to high water by subtracting the water- level adjustment (STEP 4)from measured depth to water level at site (STEP 1) ................................... Figure 13.-Reproducible computation form. 15 777T � oawn. j �-