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Home My WebLink About0079 HEAD OF THE POND LANE - Health 79 HEAD OF THE POND LANE -- -- - M arSTans M L L5 N�\ !oft No:. 3�....`....h.. Fps... �.................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH d f1...................OF........\t� - SS �� .� rlirtt Ilan for Bi_qpnstti Work,5 Tunti rurtinn thrutit Application is hereby made for a Permit to Construct (X) or Repair ( ) an Individual Sewage Disposal System at ...1.z1...... ..s ...{�o..nl... ......Mir ----M�IIS MA Location-Address or Lot Noy..Owner (�/� Address r-......._.. -( 5................. ------------ ----------------------- Installer Address dType of Building Size Lot.z . ......... feet U Dwelling—No. of Bedrooms.. V-?�...........................Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) a Other_ d fixtures ...__......-•--•-•--•-•--...._..--•--........-•---....._.._..-----••---•----•---•-•---•----••-•-•-•---•-----------------------------------------------? W Design Flow............. -----.......................gallons per person per day. Total daily flow.......... _330.__.__._............gallons. WSeptic Tank—Liquid capacity. 7.gallons Length.Z*..2`�... Width.`A'A®"�. Diameter................ Depth.J.",A x Disposal Trench—No._._A/A....... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No.___...._. .......... Diameter......1Q....... Depth below inlet...._(.......... Total leaching area.Zbb.....sq. ft. Z Other Distribution box Dosing tank ( ) ~" Percolation Test Results Performed by--- 1 / Ps ?bi................. `......3.................. •-•--•--•••-_.. Date..I - aTest Pit No. 1..!.Z......minutes per inch Depth of Test Pit.....l. ......... Depth to ground water.. ...n............. Test Pit No. 2...............:minutes per inch Depth of Test Pit.................... Depth to ground water........................ --------- -------•-------------------------�.....................•--- •-••Me jk)rVN------------- Gd --- Description of Soil..... Lsx�_.. Ta Sot — x V . .--------•-------------- W . . .....................................•---........---------.....•--•-•--•..-_...-•••.............------•-----.._....-•---•-------•••--------------.....---•----•---•--•--------•------------•------- VNature 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 TITLE 5 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. �1-------------------------- --.I. ► . ..... Application Approved By------ •• --.... ... ......................................................... •---• ....... -- ...G:_/........... Date Application Disapproved fo h ollowing reasons:-•-•-•......-----•-•---------•--•--•---•-••------••----•-••--••-•-----------------•--••-._....----._......•----- ................................................-•--...--------...-•-----••----•--•-•••--•---------......_................. Date Permit No----•----•---•---------------- - Issued.-------•-•--•-•---------.. ._.....--------......._ ------------------------- Date No.. .................... F.En.............00 ................ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ... ..............OF........P,) C t a.. ......................... AVVfiratiou for Kliiipiial Mirkii Tomitrurtion Prrmit Application is hereby made for a Permit to Construct (X,) or Repair an Individual Sewage Disposal System at: aak QLbd .m )r M A :4t.. ................................. .... . .......................................... Location Address N.; .... ...................... ............................ -7 - )!�........... T ....... ( & z_ ,P Owner Address ............ ...P ...Ro. . ... ...... Installer Address - .2.0 Type of Building Size Lot...........................Sq. feet Dwelling No. of I Bedrooms_.+1,0 P----------- Garbage Grinder ................Expansion Attic Other—Type of Building ............................ No. of persons._........__.........._..._. Showers Cafeteria Otherfixtures ................................................................................ ...................................................................... Design Flow.............5tT330...............................gallons per person per day. Total dail flow............................................gallon s. Septic Tank—Liquid capacity.KC.0-gallons Length.V..(,v."... Width.-4'A... . Diameter................ Depth.5.'A Disposal Trench—No._AM....... Width.................... Total Length...._.............. Total leaching area....................sq. ft. Seepage Pit No..........I.-...... Diameter.......�.O....... Depth below inlet....._......... Total leaching,area3-:t(2.....sq. f t. Other Distribution box (v0j Dosing tank ( ) Percolation Test Results Performed by... Date..c�]. ..... --------------------------- --- --------------------- Test Pit No. I---4%.%......minutesperinch Depth of Test Pit......�'i ............. Depth to ground water..oqn(z,------ Test Pit No. 2................minutes per inch Depth of Test Pit_...........__..._.. Depth to ground water......_............__... ----------------------------------- 71----------------------- ........"............. ................. ....... ............................ ------- ---------t----------- 0 Description of Soil.....S;�- Ol....t .......................... U ...................................................................................................................................................................................................... ........................................................................................................................................................................................................ U Nature of Repairs or Alterations—Answer when applicable................................ ..................................... ........................ ... .................................................................................................................................................................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of T I T 11 5 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. 9, k441 ............................................................ ....... ..... .... Application Approved By...... . ... .. ...I... .. . ......................................................... ..... ...... .. . .............. Date Application Disapproved fo h ollowing reasons:................................................................................................................ ........................................................................................................................................................................................................ Date PermitNo........................................................ Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...................OF...... ..: n ............................. . ........ .... Trrtifiratr of Toutpliatta THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired by.. Q___c5 _(......t-..... ............................................................................................................................................ ------- r, Pstaller ....(D .....tu.................................................................. at... ............ ........ 'bed in the has been installed in accordance with the provisions of T 5)f;�e State Sanitary as, application for Disposal Works Construction Permit No._V�_ ..................................... dated_---- ------ ....... ......................... �1_0� THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONP"D AS A GUARANTEE THAT THE SYSTEM WILYFUNPfION SATISFACTORY. DATE... 11r................................................ Insp ----------------------------------------------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH -�r� ..............OF........ ........... ...... ............ ,................. No......................... FEE.................. Disposal WaT,_k15 londrWivit "prrmit ( Permission is hereby granted..... 00( ----------------*-------------------*--------........*......................... ........ ......... to Construct ( \40f or Repair an I ividqal .Sewage Dispo yst 0....Lq-t, at N ..............................................V........ ......... ....................I.,............................................ ......... ....... Street as shown on the application for Disposal Works Construction Permit No..,g?!_!:-!!!Dated ............ ..................... ..... ..................................... .................................. DATE..----. .............................................. Board of Health FORM 1255 A. M. SULKIN, INC., BOSTON kO CAT IW10 SEWAGE PERMIT NO. Lot 127 Head of Pond Road 83-756 VILLAGE Marston Mills I N S T A LLER'S NAME R ADDRESS Robert B. OUr Co., Inc. Great WesternRoad, N. Harwich S U I L D E R OR OWNER Mc Keon DATE PERMIT ISSUED o DATE COMPLIANCE ISSUED Z II G� Of HC e 1 1 0 ' 0 3�, ,y TOWN OF BARNSTABLE LDCATION 7 y !7'cu J a 7�%�, �� t SEWAGE# VILLAGE /�-1 M . y. nn ASSESSOR'S MAP&LOT INSTALLER'S NAME&PHONE NO. V`�y w ✓ SEPTIC TANK CAPACITY 600 LEACHING FACILITY: (type) 4- (size) C C ti NO. OF BEDROOMS BUILDER OR OWNER d PERMITDATE: � I(� /D ZJ COMPLIANCE DATE: Separation Distance Between the: 4 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 'I I 5 6` • ? r '_' f �1 3�u\. i �y� 'b �b � i � � � '33? zs S S" �� n OF 275 oP, w O"PAPIT G1 MpJ� �AGHiniL_a 4 L�..' - \ l0 ACA 3s Q 8 9 x TrA.4 K_ - CdJST�,.Ci 4r2� 149 V��^ (7 T ZS' 6_ loch I �- i VACf'NT 'E, h 15ol Fief�-,A 47 4 A - mEnb '� M A0-7, l� ,Crlf•'wP i i.L, C-� � ' 13 f�L z I G10 O foa. Io fh:ca-:r A Ff�C.I L IT--( I N A LL 7 i L.%C'r' -1 7 /• �.3`i�-9 PLO 2, 1-7, TITI f . \/, sTA I �aTr �... LEGEND u.ow�''w A7a IL EXISTING SPOT ELEVATION ®x0 CERTIFIED. PLOT PLAN EXISTING CONTOUR --- ® ---- ��%�kOFIvj L.d T l?I LAT FINISHED SPOT ELEVATION M,q FINISHED CONTOUR ® - - 0 APPROVED BOARD OF HEALTH nno�sE IN No,10951 O r A ""` "' DAT E AGENT �FSS�oNALF' SCALEI �— 3 v DATE I7777 L®J4'EL1GE ENGINEERING Ca IN CLII¢�IT.�.� i CERT IFY THAT THE PROPOSED _--- EoISTEJE REGISTERED JO+� N®. ? BUILDING SHOWN ON THIS PLAN CIVIL. LAN® CONFORMS TO THE ZONING -LAWS EP!®IW i Odd,®v' '�...� OF.�ARNSTA" E AS9. a ; . 712 MAIN STREET CN. ®Ye HYANNIS MASS. z � SHEET.4 OF ...�.. ®ATE R /G. LAND SURVEYOR %IOTF TNE.4 TA.�/ ,,C 0 GH/N�, P/T A.4E /yO.4E THA:•J /2"SELOIN t8 PT.`AO/AL ♦ ET.►R CaiyC?sTE CCYEP SNAGL TO G,qA CONCst�r� 4oPYs= pip PC hlE.4VY CA 5 - /ROM G 9YL�.� Sh'.4 L : 3� JSE L �d I COYE1�$ MIAI Av7 j r, p � f /F l,'V OR/✓E' V,4 Y Jet / err vl�►� - r ��.z-: ,— 2'L:sirER917 ;.. Me • ? ter„-� . 1• e • f ,e it p • - P�l�PT ®X • o • • • a s • r o.a ; WASHED STviyE IleK I • i I • f • • • •e I �I. � • 1 P, ivr�ti Fb _ - .. ARoix..o�hcmat� � • � ! � •�.FfECT/YS � ° e�-'— 3/4 - � f2 - , o OL<PTJ+/ • e WA D STc7NE :: 1$$ 5 X T'L`5 4'1 t Get/D r. _ - • s f 1 • s • s, •` ®: PRFCA5 T,S,, r,A ,E • es t • • s • o • • e UV�1.1�7�.L:"aCIErYAT/�fl/s 18 �5t x .t o 8 /(? i o o• r a • • o o y • �- o •o P/7 0.4 ££QUI P. ;. IXY T ®LVLda/N� 8 prr ckor cm7 5 4ct /0 — = • a _ 4 S F� 2 IAA APIA" i�tt r � I � C SFE TAeuL�T10 ►) 1J1I.{�`�t37�1�/�11i�70�►. � �9 �-�"�'� ->-, :�`� �'`'�` °Ty� _ _ p _u.q,,�f�° •-y�y''A... 'S` yI y ?�.13 •�br _ '. e G,�OI! J�dT'ER TitQ,LE mozzF LZ'.+&iAif PW q Fes. `y x S1�d� 6 ` �1� .��. /►� F D.�S/6At CJIt!?'`L�t lit r� y a�i��,l► y�` g + ` o' DINAE UTIOAf'A -2's irP:ADIAIA iGARaAGX P15v05Il.L(Wfr- TOT.tL�'.ST1J►fFTEO FlOMI 330 G.4t f6ta9Y SOf� TEST / 'SOAL TFST,tZ ®J.G 7,65T ! I" IYUMdER QF LBACXlMG P/T3 9 SIDE Z r-ACH/NG PER P/F 108 A.-I Ar. � � ;y_ � G1.4TLw OF SOIL. -r&ST _ 6 /I -7/d-3 . _ 3 RFSUd.TS Ii/!T/YESSEO 8Y Co'-nO is 9 0 EOM LFr4Ci//N<s O�R I•/T �a $Q. �T. . : L o sr M �c• PER GO.0�9T10/1r R.B TE LFss TOTAL LZ4CN/NC► AREA ILGCa S'p FT. TaPSoiL � �.�ESE,4YE LEACalN6 AREA. ` PERCOLAT/0IV A,47,E 7H�r�✓ SO. FT. 3 _5 . . *lj'v.'11,vc'y �t1OPb�s i`�' �y /�j�pivr•/ LET Jz7 f/�:a� ;�='-l=cur✓� ��,q�i�- �! ORSE c-n No.10951�4 _ I t 4 O r•p FG�sTEP ��`� GL S 7. / �L�r?EDGF�N�r/NF.Ff?Ih'G CO,/.1/G 7s2 MIA ST. , �/Y.,N.viS, Np Su9"ll :0 � NO 6RoUNO YYi4TL•R ENcouly F�Ep Cl../E/VT.'AIC er t C] GM O LU./O LvA TE.t? A7- 4EL Z&, c .IOB ,von 3 Z sz sHE�T?of �- _...__. ._.. IJ y � f a _ 1 : If TROY WILLIAMS SEPTIC INSPECTIONS Certified by MA Department of Environmental Protection (508) 760-1819 40 Old Bass River Road South Dennis,MA 02660 1% C3 . conrnionweatth of MCMoC usetts We. Ao� wee Executive Office of Erty ormental Affairs Department of' CD • Environmental Protection 1fWaam F.Wald wvldcwtrsths ,TAw wBn«w SUBSURFACE SELVAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION µrsd''^y /It;lls. Property Address: 79 Ht,J n!� ;�orme t. M Address of Owner. 0o-,J t j !7�b ✓n''�"' Date of Inspection: 3 1a 6, A9c Of different) Name of Inspector:or:- /O Sy$ 3 Company Name,Address an� Ka f 7 d Telephone Number: G _CERTIFICATION STATEMENT 9 /5- I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of inspection..The inspection was performed based on my training and experience in the proper function and maintenance of ors-site sewage disposal systems. The system: Passes _ Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signature: Date: The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the 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: Check A, B,C, or D: AI SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. BI SYSTEM CONDITIONALLY PASSES: ^V/9 One or more system components need to be replaced or repaired. The system, upon completion of the replacensem or repair, passes inspection. Ind,cate yes, no, or not determined (Y, N, or ND) Describe basis of determination in all instances. If'not determined-, explain why not) The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. t SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: cA 7Y—A /0'4.R Owner. Date of Inspection: 3 Bj SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed CI 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: 1 he svctem nas a septic tank ano soli aosorption system and is within 100 feet to a surface water supply or tributary to a surface water supply. The sx'siem 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 priv ate ate water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. 'I SYSTEM FAILS:A//may 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 correct the failure. — Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool —1sed 8/15/95) 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 27 "`� -'Or A- A %,A Owner. b Date of Inspection: DI SYSTEM FAILS(continued): Static liquid level in the distribution box above outlet invert due to an overloaded or dogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to dogged 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. E) LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above: The design flow of 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 following 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. 'revised 8/15/951 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 7 9 /�c�� ' oe. Owner: Date of Inspection- 3/a G /q6 Check'if the following have been done: Pumping information was requested of the owner, occupant, and Board of Health. ZNone of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. ]./As built plans have been obtained and examined. Note if they are not available with N/A. ZThe facility or dwelling was inspected for signs of sewage back-up. ✓ The system does not receive non-sanitary or industrial waste flow V The site was inspected for signs of breakout. All system components, excluding the Soil Absorption System, have been located on the site. ,//The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. The facility 0%vne• (a-d occupants, if different from owner) were provided with information on the proper maintenance of Sub- Surface Disposal System. revised 8/15/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 2 q H e-- DIle, Owner. � b c v r•,u�.. Date of Inspection: 3 /a 6 FLOW CONDITIONS RESIDENTIAL: Design flow:,,S..LO—gallons Number of bedrooms: j; Number of current residents: S Garbage grinder (yes or no):—,!yo Laundry connected to system (yes or no): y�S Seasonal use (yes or no):_'yp Water meter readings, if available: OZ y .o— o ea t.ast date of occupancy: O C e-✓to i e CX COMMERCIAUINDUSTRIAL: IV119 Type of establishment: Design flow: aallons/day Grease trap present: (yes or no)_ ndustrial Waste Holding Tank present: (yes or no)_ "4on-sanitary waste discharged to the Title S system: (yes or no)_ Water meter readings, if available: ..ast date of occupancy: OTHER: (Describe) ast date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: Nv ,odM7 A' h c ;- "a -uh I _b I - f e-. � G/s� c �� tea. / r c�:i� H-r -}.'. System pumpeM as pan of inspection: (yes or no) lYc) If yes, Volume pumped Qallons Reason for pumping: TYPE OF SYSTEM ___JLSeptic 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) kPPROXIMATE AGE of all components, date installed (if known) and source of information: :s //c -A 102 c✓ G.,S u . sewage odors detected when arriving a1 the site. (yes or no) /✓0 revised 8/11,/9Si 5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C /SYSTEM INFORMATION (continued) Property Address: Owner. 6 e✓'�,u Date of Inspection: 3 SEPTIC TANK: (locate on site plan) Depth below grade: Material of construction: Zconcrete _metal _FRP_other(explain) Dimensions: ' X y -,k-G /OU0 '9 Sludge depth: y '1 Distance from top of sludge to bottom of outlet tee or baffle: o? Scum thickness: 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: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural ,ntegrity, evidence ofAeaka e, etc.) U L T, �, 7L 4 �w L � g _ �t;>L c.. �...� L y � L r t � t `�`� �—I,G r C O 1.— GREASE TRAP:/,l/19 :locate on site plan) Depth below grade: material of construction: _concrete _metal _FRP _other(explain) Dimensions: ,cum thickness: Distance from top of scum to top of outlet tee or baffle: "i,tance from bottom ni «t,m i- honor- of ou!tp! tee or bame Comments: recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural ntegrity, evidence of leakage. et(.) r evsed 8/1S/9S) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C t, SYSTEM INFORMATION (contlnueO Property Address: 7 / �f t w 0 7e �,L Owner: Date of Inspection: �O` 1'`'' TIGHT OR HOLDING TANK../V (locate on site plan) Depth below grade: Material of construction: concrete _metal_FRP other(explain) Dimensions: Capacity: gallons Design flow:_ _ gallons/day Alarm level: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: ,locate on site plan) Depth of liquid level above outlet invert: /4V I Comments: ;no i level and di/stribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) I2— g, 6.� PUMP CHAMBER: /V 1I (locate on site plan) Pumps in working order:(yes or no) Comments: ;note condition of pump chamber, condition of pumps and appurtenances, etc.) revised 8/15/95) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C q SYSTEM INFORMATION (continued) Property Address: 7/ Al e-o,J o -/-4t Owner. 1_/_ �¢r u Date of Inspection: l 3T�ja 6 /y6 SOIL ABSORPTION SYSTEM (SAS):✓ (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) f not determined to be present, explain: Type: leaching pits, number.d;H leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Comments: (note condition of soil, signs of hydraulic failure,, -CIA level of ponding, condition of ve tation,etc.) A/D 5 ; y S c� e A H C) k7 t l : C •, r✓g- U ,� �ro � ,, � �� CESSPOOLS: 111119 .locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: materials of construction: ndication 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: -,Y�/-7 locate on site plan) materials of construction: Dimensions: )epth of solids: :omments: (note condition of soil, signs of hydraulic.failure, level of ponding, condition of vegetation, etc.) revised 8/75/951 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continue!) Property Addn= IlcuA G r--fL, O nen Date of Inspection; 3 /a6 /�6 i SKETCH OF SEWAGE DISPOSAL SYSTEM: ind4&ties to at least two permanent references landmarks or benchmarks locate all wells within 100' �� 3a 55' as � 3SI, J-9ax Lu w 44, c-,l �)EPTH TO GROUNDWATER depth to groundwater: feet y adjusted high groundwater level net cod of determi nation or ap proximation: ,/ /� Jr , /'7�!r r+ C.� y �, I fi(+- Ci M S 1/J , /�J L.J.t.��✓ c / U Tic d i S— revised 8/15/951 9