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Home My WebLink About0001 RIVER ROAD - Health I ; ..__RIVER ROAD,MARSTONS MILLS A= 078 007.002 i I _ J i i NoZL _ Fps / ..45........ THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ..............0 ....................................... Appliration for UhiposFal Works Tongtrnrtiun ramit Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal System at: ...4Z...........Amitig_&................. ...... ........................................ Local )Addres. or Lot No. �:c• '!f�?✓................... ...•-----------------------•-•-•-•------•-.................-•----••----------------............... ilner �_ p Address W - -� .............. Installer Address Type of Building 6 Size Lot............................Sq. feet U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building ---------------------------- No. of persons________________________ Showers — Cafeteria Q' 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........................................ aTest Pit No. 1................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+' ---------------------•-----•-------•----••---------•--......------------..................--•------•......................................................... 0 Description of Soil---------------------------------------•-......----................----•-----------------------------------------------.............................................. W U ------------------------ -------------- ------------------------------- •------------ •----------------------------------------------------- •--•-------------------------------------------- ••-------------- -------------------- ---- - -----------------------------------------------------------••----------------------------.......----•-----•--•---------- ........... - Nature of Re airs or Alterations—Answer when applicable.--_-_ 2 61"------- . .............. •--•------------------------•--------------•---------------•-•--•-•-•---•----------------------.....--•---....------------------------. ----------------------------------------•----•---- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has�beese. e bo tl of health Signed ........................ Date ApplicationApproved By.................................................................................................. Date Application Disapproved for the following reasons---------------•-••---------...--•-----------------------------•-------------•--•----------------.......------•.. .........-•--•------•------....--•-----------------------------------•-••--------------•---•-•----------•......----------•------------------------------------------.................................... Date Permit No......................................................... Issued--- 41.D�71....--•--•-•-••---•--•---- � THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HE TH /------ ------ .............. u�� Application is hereby made for u Permit to Construct ( ) or Repair ( / �" Individual Sewage Disposal System ' ^ ....4/u�. �... -................4-ftirik.............. ......V: ......4...................................... Locat' Addres or Lot No. Address Address � .Type of Building Size ............................�Sq. feet Dwelling—No. of Bedrooms °"= -- ^yp= of B~~~~g ------'— No. "^ persons............................ Showers� Cafeteria `4 Other fixtures ......................................................................................................................................................Design Flow............................................ per person per day. Total daily flow............................................ . Septic Tank--Liquid capacity............gallons .-----' Wiith................ Diameter................ Depth................ Disposal Trench--No .................... Width.................... Total Leo8tb---------' Total leaching area...................sq. 8. Seepage Pit lVo---_----- Diaoetcc---_'--- Depth below inlet.................... Total leaching area.--------'og. b. Other b Dosing u� ( \ Zkm� �uo� ( ) �� ` ' �� ~ . ~" Percolation Test Results Performed by.'-.----_..-----------'------_.------' Date........................................ Test Pit No. l................ruinuteapezinc6 Depth of Test Pit..................' Depth to ground wutcc--..--_--_. Test Pit No. 2................minutes per inch Depth of Test I`iL...-------' Depth toground water........................ ---_''-_.--'__----_-_--__'_----_------'-_-_-_-----_---------'-----'-_--- � 0 Description cf Soil........................................................................................................................................................................ ---- --------------- `------------------ ------- ------------------- --`-------------- ---------------------------------------------------------------- - ----------'_-------'.-----------_-_-----'--...-_-..-'- . - -' -'- �� Nu�� Reyui� or ��u�o —Ao�erw6� ��e -� �� k14— --------------------------------------------------------------'-''r-----------'---------------- As^""~e~`' ' The undersigned agrees to install theuforedescribed Individual Sewage Disposal System in accordance with � the provisionsof TLITIS 5 of the State Sanitary [ode— The undersigned further agrees not to place the system in � ou1� a (�erb��eof Compliance 6=bee'^ �� ^ ~m "�- S5�4 �_---_-'--- '��'��'�� ~� - �� o"uy � / = Application- - - Approved _'............... ................................................................................. ........................................ Date Application Disapproved for the following reasons:.............................................................................................................. _---._-�............. ..................-- _--_..-_-_..._-_'-......--__-'_'�ate --__- Permit Date THE COMMONWEALTH OrMAssxonussrrs °' � .` BOARD | __ | �- (9rdifiratr of -~----'v--'--'-- LCAT ION SEWAGE PERMIT NO. ,iq R/Lf ?2, / '/ / VILLAGE �D /VS . F l�i9xS/ ��_LS I N S T A LLER'S NAME i ADDRESS B U I L D E R OR OWNER DATE PERMIT ISSUED DATE COMPLIANCE ISSUED 11 — —� �br 31 a� x, 5 No... =l.S�./... Finz......,9P........ THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ApplirFa$iaaa -for 43hipmFa1 Works Tomi#rurltoaa Vantit Application is hereby made for a Permit to Construct ( ) or Repair (.)() an Individual Sewage Disposal System at* --•--------------------------------------•-•--------------•---------------------------------•--- Loca ion-Addre or Lot No. � ` ----------- .:.... --------------- ............................................. ... ---------------------------------------- es; Owner Ad .... n Installer Address Type of Building Size Lot.S0.Z4?_0------Sq. feet U Dwelling—No. of Bedrooms-l9/i«_______________________________Expansion Attic ( ) Garbage Grinder (/-4-' per-, Other—Type of Building ____________________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) P4 Other fixtures W Design Flow.....................................gallons per person per day. Total daily ------------------ 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 3--____sq. ft. Z Other Distribution box Dosing tank Percolation Test Results Performed by.___. a -------------- Da e----_--_------------------- -------- Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water..-.-_-..-__-.--_--_---- f1 Test Pit No. 2................minutes per inch Depth of Test Pit.-____--.._.__-_-_-- Depth to ground water--_--.---_-.__-.--.-_--- 9 -----------------------------------------------------------------------•-------•---------•-----•--....................................... ------------- .. 0 Description of Soil-------------- -------------------------------------------•-------•----------------------------------------------------- ---------.------------------------------- x W ---------- ---------------------------------------------------- ,a V Nature of Repairs or Alterations—Answer when Plicable.-.--_-A.d.�._.-_---.-�_�-----u_____j//� 1C............................... f Sly N F •/�i9 C kE/� /�!/ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article \I of the State Sanitary Code— The undersigned fur r agrees not to place tl system in operation until a Certificate of Compliance has been sstjeb y th oar of h 1 Signed----/--------- -- --------_-----._ � ----- --��— /� 1 D e Application Approved BY .. `" s' �-� ` \.I ------ --------- --------------------- Application Disapproved for the following reasons:.............•----•---------•----------------•-••------•-------•---.....-•------............................... Date PermitNo......................................................... Issued........................................................ Date -is FEiz.....15.................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH . _...... . ... . ......OF...............................................................--...... .............. i Applirtt#inn -for Dinpnstt1 Works Tomi#rur#inn Prrmi# Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ----------------------------••----•----•--------•------...---------------------------------•...... --•-•---••--••-•••-•••••---•-------•---••-._...•-•••-..........._..............-•••-•.........--- Location-Address or Lot No. •------•---•------------------------------------------------•-----------....._.-............._...- ••-•--••-•----•--••-•---•-•••••-•-•-•.....••-•----•-......--•----•--•-............................ Owner Address W Installer Address UType of Building Size Lot..................... ......Sq. feet a Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Q' Other fixtures ------------------------------- -- W Design Flow............................................gallons per person per day. Total daily flow--------------------------------------------gallons. 04 Septic Tank—Liquid capacity------_--_-gallons Length---------------- Width................ Diameter________________ Depth---------------- W x Disposal Trench—No-____________________ Width-------------------- Total Length-------------------- Total leaching area------------.-------sq. ft. Seepage Pit No________________-__- Diameter.-_--___--__-_------ Depth below inlet------------ Total leaching area------------------sd. It. z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed bY---------------------------------r........................................ Date--------------------------------------- W W Test Pit No. 1----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water---------_--.--.__------ f=, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water------------------------ ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------•------------------------•••-------•------------------.----.. 0 Description of Soil..................................................................................................................................................................... x W VNature of Repairs or Alterations—Answer when•applica.ble......:�_.I!`.`--------------------------------- _!:.lC---------------__------_---.._.. C i-/ C /C`f" 7�iT -------------- -----------------------•---•-----•-----------------------------------------------------------------------•----------------------------------------------------•-------•-------------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed...................................................................................... -------------------------------- I D/te Application Approved By.............. -"5-'''= '' [ , '--..._.... --- -----� Z�{ -�. ......... Date Application Disapproved for the following reasons-------------------•----••--------------•-------••---••----------•---------•-•---•--•......••.........------•.... •---•----------------•----•--•----••---•---------•-----------•-•-• --••-----••------••--•-•••••••••---•....---•-••---•--••-••---.......--•••-----•----------•••------------------------•----•------.-•-•- Date PermitNo........................................................ Issued...................... ................................. Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ........... ^. ..............OF..............��...................................................... Trr#if irtt#r of Tomptitturr THISIS_� CERTI Y That the Individual Sewage Disposal System constructed ( ) or Repaired �) by..............••-•--�---- -------=- A . h , In aller at............/-----------_�C..... ...----/�..--'--------�'='- . has been installed in accordance with the provisions of Article XI of The State Sanitary Code as described in the application for Disposal Works Construction Permit No.-S.,2.!: -1-1------------------- dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCjIQ.0, SATISFACTORY. DATE................------------ -•----Li*_-I --------------•-------- Inspector------� __ -------------------------•--------------................ THE COMMONWEALTH OF MASSACHUSETTS _ BOARD OF HEALTH ............OF. ...'.......................................................... o� ..... FEE...1-................. %liv o lia nrkii �nn�#r r#inat rani# Permission is herebyra to --- '�=----- ------------------------------------------------------------------•----......----- g to Construe (�) or Re i _ )�jan ndividual Sew e Disposal System Street as shown on the application for Disposal Works Construction Permit No...�.i.�............ Dated------------------------------------------ --------------------------•--------------------- - oard of Health DATE...................Y--' g..^.................................... FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS Commonwealth of assachusetts Executive Office of Environmental Affairs Department of Environmental Protecti William F.Weld %ECEIVED GOMMM T y Coxe «Arpo Paul Csllucci MAY 6 199@arid .Struhs 0 7 Y HEALTH DEPT Q O � 0 a TOWN OF BA(iNSTABLE . � SUBSURFACE SEWAGE DISPOSAL SYSTEM INSP PART A Q, p CERTIFICATION p. Property Address:l , VeC t. Address of Owner. Date of Inspection: fYl 1`1t $, k R'k 6 (If different) Name of Inspector. ca Telephone N Company Name,Address and Number. Q 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 irspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: J �"asses _ Conditicnally Passes _ Needs Further Evaluation By the Local Approving Authority _ Fails Inspector's Signature: ,. Date: M Q $ 9q b The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing inspection. If the system is a shared system or has a flow of 10 000 p eking than desk gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer,if applicable and the approving authority. INSPECTION SUMMARY: j Check A,B, C,or D: A] SYSTEM PASSES: V0000I 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 enfiltration,.or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a Fonforming septic tank as approved by the Board of Health. (revised 11/03/95) 1 One Winter Street • Boston,Massachusetts 02108 a FAX(617)556-1049 a Telephone(617)292-SM A ice} Printed on Recycled Paper I, y SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) . jFrem eo��uc,�. Q t.Inspectiond Q t Bj SYSTEM CONDITIONALLY�ASSES (continued) Semage.back-up or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) s _. or due to a broken,settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health): K 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 CJ FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health,safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER,IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a surface water supply. _ The system has a septic tank and soil absorption system and is within a Zone I of a public water supply'well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. _ The system has a septic tank and soil absorption system and 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 ppffi. 3) OTHER (revised 11/03/95) 2 T � SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: ( Q QP V�,� � � ;r-,6_VS�0 r4 M% t\S' , f`na• da(o y g Owner. Lk W e�Q . Date of Inspection: ,,�� Q D] SYSTEM FAILS: ' 5 I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to oorrect 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 an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6"below invert or available volume is less than lJ2 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. 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. El LARGE(SYSTEM FAILS: 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 east: the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area(IWPA)or a mapped Zone II of.a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.. (revised 11/03/95) 3 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: ( R CZ°ve r \\-- �� j M a<SoN �`l1 at s. �14 • O�•b y g Owner. c�U�� At N Date of Inspection: Check if the following have been done: Pumping information was requested of the owner, occupant,and Board of Health. 2/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. NI�As built plans have been obtained and examined. Note if they are not available with N/A. ZThe facility or dwelling was inspected for signs of sewage back-up. e system does not receive non-sanitary or industrial waste flow The site was inspected for signs of breakout. N All system components, excluding the Soil Absorption System,have been located on the site. ZThe septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of ba8les or material of construction,dimensions,depth of liquid,depth of sludge,depth of scum. The .and location of the Soil Absorption System on the site has been determined based on existing information or ro�imated by non-intrusive methods. _The 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: 1 R°ice'C , mar ow M;�1vC , MA. Do1(o�$ Owner. � t{iy�o� Date of Inspeeon: C� D t�1�J FLOW CONDITIONS RESIDENTIAL.• Design flow gallons Kr pmot4 1r—vr V,� Number of bedrooms: Number of current residents: 1 Garbage grinder(yes or no):_NL6 Laundry connected to system(yes or 110425 Seasonal use(yes or no):-U / _ (' Water meter readings,if available: ..,. �D dot) W4 9 37 00(7 ')N� Lest date of occupancy: COMMERCIAL/INDUSTRIAL- Type of establishment: Design flow:_gallons/day 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 no) Water meter readings,if available: Last date of occupancy: OTHER(Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of in=t*on: �� ,�� 'OVJ s '�- 6 System pumped as part of inspection: (yes or no) If yea,volume pumped: k b 0 In ons Reason for pumping: PF FSYSTF.M . 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: ` a"c�u� V I Sewage odors detected when arriving at the site: (yes or no) (revised 11/03/95) b SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM'INFORMATION(continued) Property Address Owner. , ,�. rtv�a . 0 a�qg ,�4 0 Date of Inspection: li:A -1n�t SEPTIC TANK (locate on site plan) Depth below grade: Material of construction: concrete_metal_FRP—other(explain) Dimensions: - X pW S, a•J Shuige deice Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: Distance from top 1of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle:Q_ Comments: (recommendation for PumpingLmndition of inle d outl t tees baffles,bbaffles,depth of liquid level in relation to outlet invert,stru integrity, evidence of 1 etc.) t,.t 1 In IN • Q e ro IJ — i-0 0 n oQ" GREASE TRAP:_ � (locate on site plan) Depth below grade: Material of construction:_concrete_metal_FRP ather(e:plain) 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 level in relation to outlet invert,structural integrity, evidence of leakage,etc.) (revised 11/03/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C h SYSTEM INFORMATION(continued) Property Address:, I ,°s� R4� 'Mwls�otJ YNm1\S, �t1ct, ado Owner. ,o aoAkA Date of Inspection: TIGHT OR HOLDING TANK_ (locate on site plan) Depth below grade: Material of construction:_concrete metal_FRP_ather(esplain) - Dimensions: Capacity gallons Design flow: gallons/day _ Alarm level• Comments: (condition of inlet tee,condition of alarm and float switches, etc.) DISTRIBUTION BOX- A0 (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 bm etc.) PUMP CHAMBER_ (locate on site plan) Pumps in working order.(yes or no) Comments: (note condition of pump chamber, condition of pumps and appurtenances,etc.) (revised 11/03/95) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) � t Property �,Address' ��l Owner. e Date of Inspection: rna�g �aqb 9OIL ABSORPTION T> (sax): (locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: leeching pits, number. leaching chambers,number._ Isar-hi"g galleries,number. leaching trenches,number,length: leaching fields, number, dimensions: overflow cesspool,number. Comments: (note ponditiop of soil,signs of hydraupc failure,level of pondi5n of ve tion,etc.) 0 Y' W VO oLs CESS (locate on site plan) •• , -1 LC�� At 5 41 0 p W� "3 Wa'eY- TN �c�b�"`�. S4r�r1 ' QCtrr� , d� -�� •�c�rJN 40 N l �k. Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer v Depth of scum layer 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:_ (locate on site plan) Material 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 INFORMATION(continued) Property Address: R`►°v�pc' A , M4p5i.0w S, ma, D,bqoo Owner. ion:Inspecti Date of 1 g q b SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' � . = r d js DEPTH TO GROUNDWATER Depth to gmndwater.Aa feet method of dqtermination or aPPro i tion: G'C' W �erLevdA L-� S t fit " Se t cP 4 ns t tV S (revised 11/03/95) 9