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HomeMy WebLinkAbout0121 ROSELAND TERRACE - Health a, 1_42,1•ROSELAND TLRRACE, M. MILyL -- -- - - - - A= 103 125 _— 8_ a-1 TOWN OF BARNSTABLE LOCATION �� � � �� T � SEWAGE# VELLAAGE 4QJ/LA'S i %� ✓ �� ASSESSO� MAP&L TZ4j�2 f �y NAME&PHONE NO.'D/7/7 '7 C �J1 T 416e- ,p SEPTIC TANK CAPACITY VW • , 22, LEACHING FACII.TTY: (type) (size) J �" NO.OF BEDROOMS BUILDER O PERMTTDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility z�20 / 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 f Teaching ility). Feet Furnished by } � � I ��� _ �� t �� '�, .\ .���� �i 1 .� •, �� ��n TOZZF BARNSTABLE LOCATION d�. ���• SEWAGE # VILLALiE ✓�• /H�I IS ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY OW LEACHING FACILITY: v1� �X(0 1— (size) �b (tYPe) NO.OF BEDROOMS 3 BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the 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 leachin facility) J Feet Furnished by �n Spe v 001 �• F���+ _ I A j3ACk O a- Q 3 3I y3 S a 3 TOWN OF BARNSTABLE p LOCATION LaIL�4h� �t''. SEWAGE# VILLAGE 10,47254015 ASSESSOR'S MAP&LOT 5- INSTALLER'S NAME&PHONE NO. 1/Yl► dim b�r' So t'l �1°1C SEPTIC TANK CAPACITY _J o nn LEACHING FACILITY: (type)c;2 21-W5 (size) 10(!X!;) NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: a -1-2 - 99 COMPLIANCE DATE: f — 6 e�� 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 S 0 N� No. y Fee 0 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Zipprication for Migpool *pgtem Construction 3permit Application is hereby made for a Permit to Construct( )or Repair NX)an On-site Sewage Disposal System at: Location Address or Lot No. Owner's Name,Address and Tel.No. 121 Roseland Terrace Lot 16 G. Strathie 40 Lauren Drive Marstons Mills MA. Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. J.P.Macomber Jr. 508-775-3338 J.P.Macomber & Son Inc. Box 66 92632 Type of Building: Dwelling X No.of Bedrooms 3 Garbage Grinder�0) Other Type of Building ® No. of Persons U Showers( ) Cafeteria( ) Other Fixtures Design Flow 330 gallons per day. Calculated daily flow 660 gallons. Plan Date 12/5/7 8 Number of sheets 2 Revision Date 1 2/2 7/9 5 Title Description of Soil Lan 2i,h gni 1 2 _ 5 t Goarce sand & gravelTMedlum sand 6 . 1 Ta-,t, hale 51/22/78 Nature of Repairs or Alterations(Answer when applicable) Adding additional 1000 gallon leaching 1pit to an existing tank hex Ft nit 1 00% RxsjlRn.inn qrp..R Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued b this Boarfi of Aalth., Signed wlea Date 1 2/2 7/9 5 Application Approved by Application Disapproved for the following reasons Permit No.T/.� Date Issued ---------------- — — - -- - ----- —s t „wiy�.. - '4 „, .,......-._ a ..-:y{�+- ��.. ��.a ..�,-. .. .. •� �.•. . - .`i .....2 r+_ r�L .-«. - -, -.,..- , No. Fee '„T00 1 THE COMMONWEALTH OF MASSACHUSETTS i PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Application for.Mttpozar *pttem Conotructtou 3permit Application is hereby made for a Permit to Construct( )or Repair KX)an On-site Sewage Disposal System at: Location Address or Lot No. Owner's Name,Address and Tel.No. 121 Roseland Terrace Lot 16 G. Strathie 1V 40 Lauren Drive Marstons Mills MA. B staller's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. i comber Jr. 508-775-3338 J.P.Macomber & Son Inc. Boxox 66 66 --X, r l Type of Building: Dwelling X No. of Bedrooms 3 Garbage Grinder!jo) Other Type of Building U No. of Persons 14 Showers( ) Cafeteria( ) Other Fixtures Design Flow 330 gallons per day. Calculated daily flow 660 gallons. Plan Date 1 2 5✓78 Number of sheets 2 Revision Date 12/27/95 Title I Description of Soil T,nam ;vh ani l 2- 5 1 Coarse sand & grwrel 3 1 ma3ium sn"d i 6. 51 Test hole 5122/78 Nature of Repairs or Alterations(Answer when applicable) Adding additional 1600 gallon P leaching bit to an existing tank box & pit, 1007 Pxananaian, Arpn Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Bo of Iealth. Signed ► Date 12/2 7/9 5 Application Approved by _ i Application Disapproved for the following reasons j Permit No.T Date Issued 62 i -----—_______—= THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Certificate of Compliance - THIS IS TO CERTIFY,that the On-site Sewage Disposal System installed( )or repaired/replaced(XX)Con 12/27/9,ri by J.P-Macomber Jr. for 121' o9p1X3d Terracgr as has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. Z�_dated Use of this system is conditioned on compliance with the provisions set forth below: i No. Fee $30. 00 w THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS a Mi!gpogal *proem Conftruction i3ermit Permission is hereby granted to J.P.Macomber Jr. to construct( )repairy(XX)Yan On-site Sewage System located at 121 Roseland Terrace Marstoms Mills,Mass. and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. All construction must be completed within two years of the date below. Date: '& ' 7[� Approved by .� New Pit Existing Leach Existing 1000 tank. r /G CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS) I, Joseph P. Macomber Jr, hereby certify that the application for disposal works construction permit signed by me dated 12/2 7/9 5 , concerning the property located at 121 Roseland Terrace meets all of the Marstons Mills ,Mass . following criteria: • There are no wetlands within 300 feet of the proposed septic system • There are no private wells within 150 feet of the proposed septic system • The observed groundwater table is 14 feet or greater below the bottom of the leaching facility • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. SIGINTI) : DATE: 1 2/27/95 LICENS SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER [Attach a sketch plan of the proposed stem. Also if the licensed installer osesses a certified lot plan, P P P SY P P P > this plan should be submitted]. w D A T-141 r� F - Up �C) �O SEPi-IG Tl 1V_ z 3,�;Clv I�;C.:: 'J - 4-C1r2 G.P.D. ^� USA' 1004 6AL. . p$ql ) tur PIT ;215P_OSAL PIT - USE loco C,&.L, S WGWALL AtzEA _ So s t=. t (tg TA-1 W- I M ~ -° BOT7OAA 42EAc �O Sl=. r SO fry. �. A 1 - - ' S0 �:RD. Tcrr'A L ES16W t .425 G•p D I`� �tJt�f 32t TbTAL U41L-N( FLaW = 3306.PD. PMfdGOI.AT10L1 O&TE : ("t" I-AA,►J* Olz LE%. �.>: � ool� N • � I �y-►•/may Q�t tJ�'i N `•� h,A✓ti tip 1 9 a0 ttll t;n, iA. / 1 WoL -- -ry y 7oT Fwo .Ico.o :l8+ `M Q"L3�a .. tyv• 97 " 4'Pa� TSC IW. CPAL. Iwv. ODOo ql.•1 ��+ r 'Sox %4 Sc•-+'nc I o CCAQ6+t ( i 4�f 1 Ilhl. T•A W K SA�o GAL fL a►1D L ;� I(., O G'f2"%cl' PIT WASUIED TON ; IS. s E M SaND /o I oI , �t-OF= .era 12 - L-OGATIOW iG144TO12 '.#, i; 4�6 VI�aTF� t— KCAL 111 f I GCtZTI;='-q TI4AT TI4G A R F�ERE�1G� Aug SETt;ACK v e 4uitzEmE--uTs oF' TNe 'Tcw►.J 01- F31�IztJ�iT�l:,.r: DA'PEs BAATEIZ d. us(E I.QC.. 12CGIS•CC-.fZ�D L�IaCS ' 'SL��V6.YPCL� . TI-A1'S 0 L A W IS ►JOT Un-->GV 0 -.) AW OSTE2VIL-Lr= o MASSY 1149MEJMC-3-W " AP17LIGA.64-r �4:;ir eV.- tj-�Car, rc, tt4�-:5- - -.-_---_.... rr-UJ .. VAsLtiLirL1 SEPTIC SYSTEM MUST BE INSTALLED IN COMPLIANCE., �--�- No.7 � . '� Fim.....�.:..............._ ~� V41TH ARTICLE II STATE pTHE COMMONWEALTH OF MASS�AGlVllPTODI_ AND TOWN BOARD OF HEAL M-IONS° -,-._ - `� I ... ... _.-..... OF.s��� �J3 4'E................................. Appliratiuu -fur Biipuuttl Works Towitrur'ti on Vrrmft IApplication is hereby made for a Permit to Construct (/f or Repair ( ) an Individual Sewage Disposal System at: /% !RS7��/.5---/�%,....��5----------------------------------------- oca o -Ad ess or Lot No. caner A re .44 � Installer Address ! UType of Buildi g Size Lot_��.. _______Sq. feet Dwelling�No. of Bedrooms.-__._-_--3-----------------------------Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( ) Pa Other fixtures --------------- ------•------ .. . W Design FlowJ./Q_-!X_,_3-----------------------gallons per person per day. Total daily flow-------_ 30.---:--.._----..-----..gallons. WSeptic Tank-k iquid capacityfBMgallons Length----------------- Width......---------. Diameter_-_.--.-.--__-_ Depth_---_----.__._ x Disposal Trench—N,o--------------------- Width----._.............. Total Length-------------------- Total leaching area.............-------sq. ft. Seepage Pit No------/------------ Diameter_----:19'_-�...._. Depth below inlet.................... Total leaching area..___-...__..____.sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by-------------------------------------------------------------------------- Date_c M '..___...--. a Test Pit No. 1......11-----minutes per inch Depth of Test Pit---I _ ........ Depth to ground water,N`04!v6-_--_. LL, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water-_.-.-_-_-------.--...-. -----------•-�---------------------------------------------------------------i.....................---••-----••--•-------------------------------•---••--. Description of Soil (9-„ ��� `5�.... -. _` �/ zSvfL °`4'. `. .... 1�f9s �✓d1 / o'..... V ------ ' �. �/ e$' ` I`2 ,D�....r4 ---------------------- -------- ----------------- 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 Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has b issued by the board alth. / �� ate Application A A PP roved By.---- - 1. _-J_. e Date Application Disapproved for the following reasons:.___ ----------•-----------------•---•-------•-----------------------------------•------- ------------- ---......---••..............•-------•--------------------------------•-••------------.................................................... ...-••-----..........---•--------........._...-----•--.----- Date PermitNo........................................................ Issued-- ----------------`-------------------------•--•-•-- a d. Date ot;..... s • F' --:�- N .............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH '. ..._.._.OF,IB/ �' �' -......................... Apphratiuu -fur Uiupuutti Worko Tomi#rurtiuu Vrruift Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal System at Lot No. oca io .Address ---••--------------•--•---•- oL_F7 ^_...._.... Ownnellr��ff �� A r s w a �----44�9_, r. L.& -------------------------------- Installer Address Type of Building A Size Lot_ca�0/-�f_t___Sq. feet Dwellingle No. of Bedrooms-_-_____�____________________________ Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ____________________________ No. of persons.-_________________-____-__ Showers ( ) — Cafeteria ( ) Q' Other fixtures ------------------------------- - - W ' Design Flow.11.40.1.,3....................... per person per day. Total daily flow-------3i 33 ------------------------ WSeptic TankkL,iquid capacit)4 _gallons Length---------------- Width-------......... Diameter---------------- Depth-.-------------. x Disposall,4T-rench—No_____________________ Width-------------------- Total Length-------------------- Total leaching area--------------------sq. ft. 3 _•Seepa"ge Pit No-----/............. Diameter...... Depth below inlet.................... Total leaching area.-----------------sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed b ____________________________________________________ Date .�_-Ay7r_ Test Pit No. I__.__eA------minutes per inch Depth of "Pest Pit_-/,w2___.......... Depth to ground waterA-_-'0�e_.__-__- (4 Test Pit No. 2----------------minutes per inch Depth of Test Pit.................... Depth to ground water------------------------ -----------------------------------------------------------------------------a .. ----•-•-••-------- ----------- - 0 Description of ..... ".r- "-- — COAOI_...54WAD AtV-0 __ w6�1?AJVE-4 -'-•••-/��`�" �A�,�----- -------- --------- ------- - ------------------ ---------------- --- x ------------------------- ------------------------------ ------------------------------------------------------------------------------------------------------------------------------------------------ U Nature of Repairs or Alterations—Answer when applicable____________________________________________....................................---------------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------- ------ Agreement: The under"'signed agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article YI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has b issued by the board alth. FSi� - -- --- ----------- ....... --------- f jOate r Application Approved By`-"-- --- t�''�� ----------------------------- ---�� ':�r-,7-•----- Application Disapproved for following reasons-------------- ------------------------------------------------•-----------.._.__.---------Dd2e•••••----•---- •--••-••••--•---------•-••-••....-•-•-••••-•-•---------------••••••------•--•-•-••-••--••---•---•----•-•----------------•--•.....•••••-••-••---••••••---•------•----•••-•-------•------•-••------------- Date PermitNo......................................................... Issued........................................................ Date .rc THE COMMONWEALTH OF MASSACHU°SETTS BOARD OF HEALTH mu.,rdifiratr of Tontphattrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed 4--or or Repaired ( ) by---... AHW--------A-4-4.'/"7.22............................................ Installer at-•�-•0-7--*110------V-5 --- _/ / l r- ,,�`` � 1 n� r 1`- ` has been installed in accordance with the provisions of cle<I of The State Sanitary Code as described in the application for Disposal Works Construction Permit 114W. _1---------------------- dated_ - - ................... THE ISSUANCE OF THIS CERTIOICATE SHALL NOT BE CONSTRUED A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. j DATE.............. -• ................ ( = Inspector M THE COMMONWEALTH OF MASS CHUSETTS BOARD OF HEALTH sic00A.".......... . ...OF.. Af-:'NS7.*?c.6 --.----.---.-......._.......-......••--------• • BisVuiitt1 Workp C ontitrur# uit Vrrmi# Permission is hereby granted.--- _ {/ AAA-- --------------------- ----••---------------.....-------•--•-•------•••--•---••-••----...•--- to Con truce or Repair ( ) an Individual Sewage Disposal System Street as shown on the application for Disposal Works Construction rmit _________ Dated_/;?-- J2_r7,¢--!-------------- ' f DATE Board o -------- --- ------�-'-- --------------...-•••••••---------- FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS '�' c Lac' �.:�.- >r cz1►.ro _ �_ __ _ .- — -_ - �dl L� 1~LOW _ :ICE x 3 _'3(� 6-P•T2. �E�t-IG T< l►C. = -��p,r ISG `/o 4~9rj 6.Po. PiT PosAL PIT - L,SE l Ocx:> GAL• 1 r W6V,/A" M A. = tSo G.P. Ta•i � BVT'ro/.'l TOTS L 425 G.P.D. so TaTA L- UA►L-�-f Pt=-iZGDLQTIOLJ Z&TE t"IQ SAMI-Y o2 0 - r Tor Fwo e roo.o =Cis �J �w��e r I�V� -1 I•V �JLiSO►t� 4wlopr 1OaC> 1�1V r1 2'14. f '�X %i SEpr-IC 10 Iuv t Ta�1►G coaa<sa logo q 5 4 GAL. Le cH ;•k PIT r wIru S Iz 1'/4 r�2 Wp5418D STowIE �,Q" jpND C,a TIFIF--L7 pL.bT P_L.ISI�I 1 P20�-ILA L h GA T I O t-4 MI" -- 12 ti,-!co Sc f� I GGtZTt�� -r -4A-r T1-1G 1-'OvIJDATIC�N StlChv►J i�t. At l � >n' Ri G� Wt-R OW -e0AAPLVG W I"C'k TWG- -SIDir.l. (WF-- { ' Aur-> 5E`rt3AGIG VC-QUIQGAAc QTS OP -r"C t -TOW Q Or-- S� iTA�'��. . PL, AIL,,, c-co 1 I'(✓ �'+-1 XTE tZ, P- t Q G. TI-115 PL-Aw IS WOT ek"Sev 064 AW aSTECLVIt�t.C- a MASS iW-9r�c1MENT cc}4:./t_�{ TIC- C��r~;o 51d4wt� Apv> _t GA,"-r wt�r 4� Usera Ilo hr_TGQMIw l vY l_INi^�� J Taaw pAtJAt���. COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS 7 DEPARTMENT OF ENVIRONMENTAL PROTECTION `/ / TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 121 Roseland Terrace Marstons Mills, MA 02648. Owner's Name: Ann Goulart �� ��9� Owner's Address: Date of Inspection: July 14, 2005 �.3 Name of Inspector: (Please Print) James M. Ford Company Name: James M. Ford ¢ =� Mailing Address: P.O. Box 49 Osterville,MA 02655-0049 co Telephone Number: (508) 862-9400 — M CERTIFICATIONSTATEMENT I certify that I have personally inspected the sewage disposal system at this-address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CAM 15.000). The system: ✓ Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails 4 Inspector's Signature: Date: July 20, 2005 The system inspector shall submi a opy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completin is inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments ****This report only describes conditions,at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 121 Roseland Terrace Marston Mills, MA Owner: Ann Goulart Date of Inspection: July 14, 2005 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: ✓ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in 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. If"not determined",please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank 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 of sewage 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 removed 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 pipe(s)are replaced obstruction is removed ND explain: 2 Ili Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 121 Roseland Terrace Marstons Mills. MA Owner: Ann Goulart Date of Inspection: July 14, 2005 C. 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 public 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: 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 any)determines that the system is functioning in a manner that protects the public health,safety and 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 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 or more 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 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,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 3 Page 4,of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 121 Roseland Terrace Marstons Mills, MA Owner: Ann Goulart Date of Inspection: July 14, 2005 D. System Failure Criteria applicable to all systems: You must indicate either"yes"or"no"to each of the following for all inspections: Yes No ✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than ''/2 day flow ✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_. ✓ Any portion of the SAS,cesspool or privy is below high ground water elevation. ✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ✓ Any portion of a cesspool or privy is within a Zone 1 of a public well. ✓ Any portion of a cesspool or privy is within 50 feet of a private water supply well. ✓ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for 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,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] No (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails: The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large System: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 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 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 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 threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 4 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 121 Roseland Terrace Marstons Mills , MA Owner: Ann Goulart Date of Inspection: Julv 14, 2005 Check if the following have been done: You must indicate"yes"or"no"as to each of the following: Yes No ✓ Pumping information was provided by the owner,occupant,or Board of Health ✓ Were any of the system components pumped out in the previous two weeks ? ✓ _ Has the system received normal flows in the previous two week period? ✓ Have large volumes of water been introduced to the system recently or as part of this inspection? ✓ Were as built plans of the_ p system obtained and examined . (If they were not available note as N/A) ✓ Was the facility or dwelling inspected for signs of sewage back up? ✓ _. Was the site inspected for signs of break out? ✓ _ Were all system components,excluding the SAS, located on site? ✓ _ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees,material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ✓ _ Was the facility owner(and occupants if different from owner)provided with information on the proper 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. ✓ _ 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)]. 5 Page 6 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 121 Roseland Terrace Marstons Mills. MA Owner: Ann Goulart Date of Inspection: July 14, 2005 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 3 Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system(yes or no): n1a [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings, if available(last 2 years usage(gpd)): Unavailable Sump Pump(yes or no): No Last date of occupancy: Currently occupied COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sqft,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 no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Pumped 3 vears ago-per owner Was system pumped as part of the inspection(yes or no): No 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 the current operation and maintenance contract(to be obtained from system owner) Tight Tank Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: A new pit was installed in approximately 1996-per as built card Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 121 Roseland Terrace Marston Mills, MA Owner: Ann Goulart Date of Inspection: July 14, 2005 BUILDING SEWER(locate on site plan) 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: ✓ (locate on site plan) Depth below grade: 2' Material of construction: ✓ concrete _metal _fiberglass _polyethylene _other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 1000 gal. Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: 3" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: 10" How were dimensions determined: Measuring stick Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): Cement tees were Present. The liquid level was even with the outlet invert There did not appear to be any signs of leakage. The outlet cover was 5"below Qrade. GREASE TRAP: None (locate on site plan) Depth below grade: Material of 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 pumping: Continents (on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 121 Roseland Terrace Marstons Mills. MA Owner: Ann Goulart Date of Inspection: July 14, 2005 TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(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: ✓ (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Even Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box,etc.): The D-box was level. No solids were present. PUMP CHAMBER: None (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.): 8 f Page 9 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENT S SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 121 Roseland Terrace Marstons Mills, MA Owner: Ann Goulart Date of Inspection: July 14, 2005 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type ✓ leaching pits,number: 2-6'x 6'(1000 zaL) leaching chambers,number: leaching galleries,number: leaching trenches,number, length: leaching fields,number,dimensions: overflow cesspool,number: Innovative/alternative system Type/name of technology: Commnents (note condition of soil,signs of hydraulic failure, level of ponding, damp soil,condition of vegetation, etc.): The new leach nit had Y ofliquid on the bottom The scum line was at the sane level The bottom to grade was 9' The cover was 16"below grade. The older pit was dry The bottom to grade was 9' There did not appear to be any signs of failure CESSPOOLS: None (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions o:cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments (note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation,etc.): PRIVY: None (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.): 9 i Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 121 Roseland Terrace Marstons Mills. MA Owner: Ann Goulart Date of Inspection: July 14, 2005 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. 8 o a. Q 3 3 S I 53 s Ya 3 10 G Page 11 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 121 Roseland Terrace Marstons Mills. MA Owner: Ann Goulart Date of Inspection: July 14, 2005 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 40+/- feet Please indicate(check)all methods used to detennine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) ✓ Checked with local Board of Health-explain: topographic and water contours maps Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Using Barnstable topographic and water contours maps, the maps were showing approximately 40'+/-to ground water at this site. This report has been prepared and the system inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed, written or implied, relating to the system, the inspection and/or this report. 11 _ V BORTOLOTTI CONSTRUCTION,INC. 765 WAKEBY ROAD,MARSTONS MILLS,MA 02648 508-771-9399 508428-8926 FAX: 508428-9399 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: /,,,? r - � r'c� 1776r-3 Dien �J. Date of Inspection: Inspector's Name: Owner's Name and Address: �� CERTIFICATION STAT .MENT! I certify that I have personally inspected the sewage disposal system at this address and that the informa- tion reported below is true,accurate and complete as of the time of inspection.The inspection was per- formed 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 Ev luation B e Local Aproving Authority Fails Inspector's Signature: Date: / �'-� The System Ins "y Inspector shall submit copy of this inspection report to the Approving au `' thii'y ty(30)days of completing this inspection. If the system is a shared system or has ad s' gpd or greater,the inspector and the system owner shall submit the report to the r riate region � d office of the Department of Environmental Protection. The original should to thNrA towner` and copies sent to the buyer, if applicable and the approving authority. . INSPECTION SUMMARY: �9 91 A)SYSTEM PASSES: I have not found any information which indicates that the system viola riy,of a failur criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated=are4ndicat below. B)SYSTEM CONDITIONALLY PASSES; One or more system components need to be replaced or repaired. The system,upon comple- tion of the replacement or repair,passes inspection. Indicate yes,nor,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 sep- tic tank is replaced with a conforming septic tank as approved by The Board of Health. Sewage backkup or breakout or high static water level observed in the distribution box is due N1:.., ,�';, t 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): SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Broken pipe(s)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 C)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. 1 2)SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER '? SUPPLIER,IF APPROPRIATE)DETERMINES THAT THE SYSTEM IS FUNCTION- ING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE Fsr ENVIRONMENT: aw 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 with 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 ' R 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 the facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less #t�A than 5 ppm. D SATEM FAILS: aY 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 shou,)d be contacted to determine 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. 1� Discharge or ponding of efluent 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 clog- ged SAS or cesspool. k !f 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 '?wi pipe(s). Number of times pumped J' ' litJiir e f Y SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (coutimied) 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. E)LARGE SYSTEM FAILS: The following criteria apply to a large system in addition to the criteria above: The design flow of a system is 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 followingF"; conditions exist: 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. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST 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 atleast 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. _ 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 site. t,/fhe septic tank manholes were uncovered,opened,and the interior of the septic tank was in- +' spected for condition of baffles or tees, material of construction,dimensions,depth of liquid, r' depth of sludge,depth of scum. G/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. -3 'B'V <h4 Z ,xF a 1 i I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST(continued) The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Subsurface Disposal System ' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION FLOW CONDITIONS RESIDENTIAL Design Flow: allons Number of Bedroocns:�_ Number of Current Residents: cZ-r� Garbage Grinder: 0 Laundry Connected To System: F?S Seasonal Use: d f Water Meter Readings,if available: Last Date of Occupancy: T___6,-ne v� sa COMMERCLALlIND iSTRLAL:%/6 Type of Establishment: ` Design Flow: gallons/day Grease Trap.Present: (yes or no) '4 Industrial Waste Holding Tank Present: i Non-Sanitary Waste Discharged To The Title V System: Water Meter Readings, If Available: Last Date of Occupancy: �r OTHER: Describe) Last Date of Occupancy: GENERAL INFORMATION `/✓' _,� ,/� PUMPING RECORDS and source of information // r4r) iYi �G IC�0' System Pumped as part of inspection: If yes, volume i limped: gallons Reason for pumping: TYPE OF SYSTEM: ZSeptic Tank/Distribution Box/Soil Absorption System Single Cesspool r r' Overflow Cesspool ;fi Privy Shared System(If yes,attach previous inspection records, if any) a*f Other(explain): ,kPI)ROXIMATE AGE of all components,date installed(if known)and source of information: KlOrb I&Y V 's lei :° >n- Sewage odors detected when arriving at the site: f7 Z: 4_ >a�� 0l` , I " SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C GENERAL INFORMATION (continued) SEPTIC TANK: C� Depth below grade: Material of Construction: V-60'ncrete metal FRP Other (explain) — Dimisions:_ Sludge Depth: rt/7nP Scum Thickness: Iralle Distance from top of sludge to bottom 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, c.) J'-/S a ?Ni f P j7 s GREASE TRAP: Depth Below Grade: Material of Construction: concrete metal_FRP_Other (explain) t+,:', Dimensions: Scum Thickness: Distance from top of scum to top 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.) TIGHT OR HOLDING TANK: 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: Depth of liquid level above outlet invert:" /C 6 Comments: (note if level and distribution is equal,evid ce of solids carryover,evidence of leakage into or out of box,etc.) icy ��/ �, -17 r PUMP CHAMBER: Pump is in working order: Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) .t; SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) SOIL ABSORPTION SYSTEM (SAS):��� (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: Leaching pits, number: Leaching chambers, number: Leaching galleries,number: Leaching trenches, number, length: Leaching fields,number,dimensions: Overflow cesspool,number. Comments: (note condition of soil, si s of hydraulic failure level of pond'n condition of v ge on, etc.) �� / G� G Ui -C' �S f r/ / �Z- 1 ho 4 inn, CESSPOOLS: .4zd Number and configuration: Depth-top of liquid to inlet invert:Depth of solids layer: Depth of scum layer: Dimensions of Cesspool: r Materials of construction:- Indication of groundwater: ` Inflow(cesspool must be pumped as part of inspection) .j Comments: (note condition of soilk, signs of hydraulic failure, level of ponding,condition of vegetation, etc 411 PRIVY: Materials of construction: Dimensions: Depth of Solids: k Comments: (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, d etc.) y t NI.�,Iii:�1.13.t !y SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM. INFORMATION (continued) SKETCH OF SEWAGE DISPOSAL SYSTEM: Include ties to atleast two permanent references, landmarks or benchmarks. Locate all wells within 100 Feet. C—A/ O j J DEPTH TO GROUNDWATER: Depth to groundwater: 2 Z- Feet , �� Meth o�f Aeterrtunation or Approximation: /� /29, 11,,a1V ZZ (/ "i°I^/DID �c� Glib `l n -7-