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HomeMy WebLinkAbout0625 HUCKINS NECK ROAD - Health z3� d�� TOWN OF BARNSTABLE LOCATION �< L �yG'e�/�''��'�����SEWAGE# VILLAGE ASSESSOR'S MAP.&PARCEL Z-1 INSTALLER'S NAME&PHONE NO. Z �`130 �/� SEPTIC TANK CAPACITY 4-e'44- LEACHING FACILITY:(type),-'- NO.OF BEDROOMS OWNER PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility /a 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 ,oe � S T o - 3 ;L � �' � 6 625 Huckins Neck Road A= 234-049 Centerville 7 aF Town of Barnstable P# Department of Regulatory Services ' RAJUM NAM ABM = Public Health Division 2 200 Main Street,Hyannis MA 02601 Date bb 0 Date Scheduled ' Time, Fee Pd. �- Soil Suitability Assessment or S - .f a Dis t ' Performed.gy: Witnessed By: l V LOCATION& GENERAL INFORMATION Location Address �� r� v J, _- .p��o Owner's Name 6 Address -PAS e- Assessor's�1_ arcel: _ [ � _ Engineer's Name 4e lvAl dNEW CONUCTION REPAIR Telephone# J e,7 zll Land Use Slopes(%) Surface Stones Distances from: Open Water Body ft Possible Wet.Area Drinking Water Well ft Drainage Way ft Property Line -----__ft Other ft SKETCH:(Street name,dimensions of lot,exact loeati ns of test holes&perc tests,locate wetlands in proximi ty y to holes) W r IDS Tq Parent material(geologic) Depth to Bedrock Depth to Groundwater. Standing Water in Hole: Weeping from Pit Face Estimated Seasonal High Groundwater Method Used: DETERMINATION FOR SEASONAL HIGH WATER TABLE Depth Observed standing in obs.hole: Depth to weeping from side of obs.hole: in. Depth to soil mgttl : in Index Well# Reading Date: Index Well level in' Groundwater Adjustment fr. Adj,factor- Adj.groundwater Level PERCOLATION TEST l�atr . �, e Observation Hole# ` �)� Time at 4" Depth of Perc * �p , � ` Ab_ Time at 6" Start Pre-soak rime @ 2 � ! Time(9"-6") End Pre-soak ` 7 11 Rate Min./inch Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole Data To Be Completed on Back----------- ***If percolation test is to be conducted within 100' of wetland,you must first notify the Barnstable Conservation Division at least one(1) week prior to beginning. Q:SEPTICIPERCFORM.DOC e DEEP.OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. a i tenc ravel DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in:) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency,% ray 1 DEEP OBSERVATION HOLE LOG Hole# 'Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency, a Gravel DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders: Cons i ten ravell Flood Insurance Rate Man: Above 500 year flood boundary No es t/ Within 500 year boundary No Yes Within 100 year flood boundary,No__ Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervi us terial exist in all areas,observed throughout the area proposed for the soil absorption system? If not,what'is the depth of naturally occurring pery ous material? L� Certification I certify that on (date)I have passed the soil evaluator examination approved by the Department of Enviro mental Protection and that the above analysis was performed y me consistent with the requir experd nd r' described in 310 CMR 15.017. tL Signat Date ®�✓ Q:WEP71C%PERCFORM.DOC 71 No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in coWS PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSET ftpYitation for disposal *pstrm Construction Permit Application for a Permit to Construct(k< Repair( ) Upgrade( ) Abandon( ) Complete System ❑Individual Components Location Address or Lot No. 6, $` C�/� �°�E wner's Name,Address,and Tel.No. Assessor's Map/Parcel 9 3 0' Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building G�'�c1� No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 3 3 gpd Design flow provided ��� gpd Plan Date 9�IJ ��. Number of sheets 0, Revision Date Title Size of Septic Tank -W Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) 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 Certificate of Compliance has been issued b Kis oard of Health. ed DateFF ON d/ Application Approved by Date Application Disapproved by It Date for the following reasons Permit No. r Date Issued No. { \ Fee THE LNWEAL H OF MASSACHUSETTS Entered in co puler: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes Rpplication for Disposal ,6pstirm Construction permit Application for a Permit to Construct(kfo Repair( ) Upgrade( ) Abandon( ) omplete System ❑Individual Components Location Address or Lot No. ��f ,, vC,��,�. !` /!�'t�� Owner's Name,Address,and Tel.No. Assessor's Map/Parcel .7 Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. �JTA70-7 t3��so�'j /J.'�`/�'7 -eW'/ Type of Building: Y� Dwelling No.of Bedrooms - 1 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building*,Oe'd J' i No.Of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd 1Design flow provided .7�d gpd Iw Plan Date > Number oif sheets / Revision Date Title Size of Septic Tank,,y e4e Zry o (57A e Type of S.A.S. Description of Soil j Nature of Repairs or Alterations(Answer when applicable) � r Date last inspected: Agreement: ` The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in i accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued bytes oard of Health. ed t+ Date I Application Approved by r` %� r, f j ' 1, y Date f i Application Disapproved by Date for the following reasons Permit No. ` Date Issued -73 --- :.- ----- -_----------- ---- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETT Certificate of Compliance a THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( Repaired(Aol Upgraded( ) Abandoned( )by (—f Pe C at orl s" ' v &b has been conqucted in acco,rdanc ` with the provisions of Title 5 and the for Disposal System Construction Permit No. C }ALL Installer er4eo!r� ej'�d'}�It Designer 45.4 A14.0 01 p/-- #bedrooms Approved design flow JP'.s✓© gpd The issuance of this perm' shall not construed as a guarantee that the system it fu lion as designed. F� p �Date J Inspector � ����✓ I --- ---- --------------- --_ ---� --_-.-- ----.---- ----.--------------- - ------- ---- ---/--- -----1------J­-­ ------ No; Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS Misposal. 6pstem onstrnction J)Prmit Permission is hereby granted to Construct( !.)"'Repair( 4y� Upgrade( ) Abandon( ) System located at <<9 5— ' 4''G 'i and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Cons ctioh must be completed within three years of the date of this permit. Date ( Approved by J J TOWN OF BA.RNSTABLE LOCATION SEWAGE # VILLAGE CCtQ;1k, �.���ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY S �'As►-a LEACHING FACILITY: (type) QU-ILI-1-Vs-Q CX4S I (size) yl NO.OF BEDROOMS__ t BUILDER OR OWNER 5 t Aa SATE: COMPLIANCE DATE: Separation Distance Between the: l Maximum Adjusted Groundwater Table to the Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) to. Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facili ) N-& Feet Furnished by_ 1�e , cD +` r � � � � 1 � Z � � _. �� �� 3Y� �� �� � � Town of Barnstable �IME�° Regulatory Services Thomas F. Geiler, Director k e, • Public Health Division v Mass. MASS. �. �Ar i639' a�� Thomas McKean, Director FD MA'S 200 Main Street, Hyannis,MA 02601 Office: 508 862 644 r Fax: 508-790-6304 Date: �Z Z�6 Sewage Permit# "���3%3sa Assessor's Map/Parcels) f' ';9 Installer &Designer Certification Form Designer: c ���� `'/� Installer: / t Address: �� ��`''�d "/ . Address: l y On �� was issued a permit to install a (date) (installer) �(� septic system at O Ly_1 i0,/ based on a design drawn by (address) ��r/• ►"1� dated 9 (designer) I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. Stripout (if required) was inspected and the soils were found satisfactory. I certify that the septic system referenced above was installed with major changes (i,e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State & Local R- ',rions. Plan revision or certified as-built by designer to follow. Stripout (if r, -cted and the soils were found satisfactory. OF DAVID (Installer's Signature) 2 MASON �1 9 No.1066 E31 /ST esi, er s Signature) ), \✓ �,.,�� PLEASE RETURN TO BARNSTABLE PUBL._ _IfE OF COMPLIANCE WILL NOT BE ISSUED UN i ii, uu i ri x ni,3 r ORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. gAoffice forms\desionercertitication fonn,doc r -_. COMMON\\EALTH OF :•LkS,S.\CHL SETTS -- E)�ECUTIVE OFFICE OF E.NVIRONNIENTAL AFFAIF- DEPARTMENT OF ElvvmoN. MENTAL PROTECTIOIt ONE n'INTI R STREET BOS 0210- !.ri: 292.5.io-i TRUDY COXF Secretary ARGEO PAt?L CELLCCCI AVID B. STRUHS 8 Commissioner Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM � PART A CERTIFICATION hY..�.�..,� (�u Imo; �• "`- \��j s„� Property Address: �,�� !� Name of Owner b I �`�\wivt��.t.. Address of Owner: r Q 1 `tll 1�Date of Inspection: Name of Inspector: (Please Pnnt)I [ •Ch Q r, %t J EC_K U ~' 1 am a DEP approved system inspector pursuant to Section 15.[340 of T-rde 5(310 CMR 15.00 9i99 Company Name: fl ,[ �k N,'rL Mailing Address:-�l&, a Telephone Number: / -:�'{2- ) CERTIFICATION STATEMENT I certify that 1 have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: Passes _ Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority Fails — \ . Date: Inspector's Signature: .P)✓moo t�� The System Inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)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. NOTES AND COMMENTS L ry revised 9/2/98 P age tdtt �i Prntedea Recycled Paper • S SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) i 'roperty Address: ,o Z J" .2-"J Date of Inspection: ( 11 U 1A INSPECTION SUMMARY: Check A, B, C, or D: A. SYSTEM PASSES: XI have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure criteria not evaluated are indicated below. COMMENTS: B. SYSTEM CONDITIONALLY PASSES: One or more system components as described in the "Conditional Pass- section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Indicate yes, no, or not determined (Y. N. or NO). Describe basis of determination in all instances. If "not determined', explain why not. _ The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or the septic tank, whether or not metal, is cracked,structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. _ Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced _ The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed revised 9/2/98 Page2of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: Date of Inspection: C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: /r Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ Cesspool or privy is within 50 feet of surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 1 r l 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 AND SAFETY AND THE ENVIRONMENT: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. _ The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 31 OTHER I f s 1 r' fj{F revised 9/2/98 Page 3of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: Date of Inspection: D. SYSTEM FAILS: You must indicate either "Yes" or "No- to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15/.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage into 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 overloadedYCI,gged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available volume is les than 1/2 day flow. _ Required pumping more than 4 times in the last year NOT due to clogged o obstructed pipe(s). Number of times pumped_. Any portion of the Soil Absorption System, cesspool or privy is below he 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 ell. _ Any portion of a cesspool or privy is within 50 feet of a priv to water supply well. Any portion of a cesspool or privy is less-than 100 feet b t greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been nalyzed to be acceptable, attach copy of well water analysis for coliform bacteria: volatile organic compounds, ammo - nitrogen and nitrate nitrogen. E. LARGE SYSTEM FAILS: Ybu must indicate either "Yes" or "No- to each of the following: The following criteria apply to large systems in addition the criteria above: The system serves a facility with a design flow of 10�:000 gpd or greater(Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitr g n sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone 11 of a public water supply well) The owner or operator of any such system s 11 upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further informa ion. revised 9/2/98 psge4of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: I�ZSCYC�'►•� 6�1'�CJ� Owner: M •L . 1`Jolr_oLS ;tl Date of Inspection:`-C J l Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes No kr Pumping information was provided by the owner, occupant, or Board of Health. None of the system components have been pumped for at least two weeks and-the system has been receiving rwrmal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. t� 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 the site. ICI Pt The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles `T 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: N 1, Existing information. For example, Plan at B.O.H. Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) (I 5.302(3)(b)) 4�( The facility owner(and occupants,if different from owner) were provided with information on the properxnaintenan".of Subsurface Disposal Systems. revised 9/2/98 Page Sof11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM. PART C SYSTEM INFORMATION 'roperty Address: �,ZS �C_ckN Owner: �t -(r. . it l a> 'c,-- Date of Inspection: Lt � �y 7 C-I FLOW CONDITIONS RESIDENTIAL: Design flow:330 g.p.d.lbedroom. Number of bedrooms (design): �) Number of bedrooms (actual):Ob Total DESIGN flow Number of current residents: 0 Garbage grinder(yes or no): r4 -y Laundry(separate system) ( es or If yes, separate inspection required Laundry system inspected jyej or no) Seasonal use (yes or no): Water meter readings,if available (last two year's usage (gpd): � Sump Pump (yes or no):_ Lest date of occupancy: C ArmAt&U Prt COMMERCIALtINDUSTRIAL: Vv Type of establishment: Design flow: gpd 1 Based on 15.203) Basis of design flow 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 information: System pumped as part of inspection: (yes or no) N If yes, volume pumped: gallons Reason for pumping: TYPE OF SYSTEM Septic tank/distribution box/soil absorption system X _ Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes, attach previous inspection records,if any) I/A Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components, date installed lif known)and source of information: yy y" Sewage odors detected when arriving at the site: (yes or no) I revised 9/2/98 Page 6(if II SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) 'roperty Address: Owner: Date of Inspection: BUILDING SEWER: (Locate on site plan) Depth below grade:_ Material of construction: _cast iron_40 PVC _ other (explain) Distance from private water supply well or suction line Diameter Comments: (condition of joints, venting, evidence of leakage, etc.) SEPTIC TANK:_ (locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_Fiberglass _Polyethylene _other(explain) If tank is metal, list age_ Is age confirmed by Certificate of Compliance_(Yes/No) Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: 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: How dimensions were determined: comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth o liquid level in relation to outlet invert, structural integrity, evidence of leakage,etc.) GREASE TRAP: (locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_Fiberglass _Polyethyle a_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: Comments: (recommendation for pumping, condition of Inlet and outlet tees r baffles,depth of liquid level in relation to outlet invert,structural integrity, evidence of leakage,etc.) revised 9/2/98 Page 7of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) +roperty Address: Owner: Date of Inspection: TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or at time of, inspection) (locate on site plan) Depth below grade:_ Material of construction: _concrete_metal_Fiberglass_PolyetFylene —other(explain) Dimensions: Capacity: gallons Design flow: gallonslday Alarm present Alarm level: Alarm in working order: Yes _ No_ Date of previous pumping: 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: Comments: (note if level and distribution is equal, evidence of solids carryover, evid ce of leakage into or out of box, etc.) PUMP CHAMBER:_ (locate on site plan) Pumps in working order:(Yes or No) Alarms in working order(Yes or No) Comments: (note condition of pump chamber,-condition of pumps a d appurtenances, etc.) revised 9/2/98 Page 9ortt SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) •roperty Address: Vew Owner: Date of Irtspecbon: I Cl p, SOIL ABSORPTION SYSTEM(SAS): S (locate on site plan, if possible: excav tion not required, location may be approximated by non-intrusive methods) If not located, explain: Type: leaching pits, number:_ leaching chambers, number:_ leaching galleries, number:_ leaching trenches, number, length: leaching fields, number, dimensions: overflow cesspool, number. ( S�>iMr't, Alternative system: Name of Technology: Comments: In condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition vegetation, etc.) V CESSPOOLS: (locate on site p and 11 Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: (,p'` )epth of scum layer: C. " Dimensions of cesspool: 5,t f! )L li Materials of construction: Indication of groundwater: (v inflow (cesspool must be pumped as part of inspection) Comments: (ngte condition of soil, signs of hydraulic failure, level of ponding, condition of vg elation etc. w I PRIVY:L } (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.) revised 9/2/98 PaRe9of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) 'roperty Address: )wner: t� -C, , �Ou 4- Dale of Inspection:(4 f lC,C1 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) t revised 9/2/98 Page 10of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (cominued) roperty Address: Owner: t� ,� • �jpy�ct�j icy Date of Inspection: NRCS Report name --- Soil Type_ _ — -- --- - — Typical depth to groundwater ___ USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope Surface water Check Cellar Shallow wells i Estimated Depth to Groundwater `�U Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observed Site (Abutting property, observation hole, basement sump etc.) Determined from local conditions Checked with local Board of health Checked FEMA Maps Checked pumping records Checked local excavators, installers Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) c:� �j v ✓:i:.� l G(c), C v 7 !-'C�G` ^j j tC1�t revised 9/2/98 page ilorn - ..-.v..•x•.rmnr+a.....,.-n�rmKamnpea+r�r �� a ! gl' ASSESSORS MAP - - ; r -- r+— I LS i 1-10LL- LOCH PAl1CLL : -FLOOD 5U I L �VALUAT011 t ��' �r � � 1) I he uisballalnou shall cunii.;, wills I ills V and '1'owu vl'�" I crud of i WI11IhSS : IDt REFERENCE !: ► t2 I lealth Regulations. DATE: I 2) I'he installer shall verily the lOca(j011 of ulilit sewer invel(s and septic f Ei1COLAT I Oil IIA1 E: mil 'jiln , l�- i coniponenls prior to installation sued seUilig base eleva(ions. .. _ __._m_..__ ___.__ �.__. .__ __ __ �a _- ( ' al J i'B 3) All gravity septic piping to he<i inch Sch 4O Pvc at 1/8', per lb t. 'fhe lirst two leet out of the d-box to Ilia leacbuig sli�ill be level. 11I- I 1I1-2 q) I Inns plan is not to be utilized liar properly line detell, a(ion lionsIany other l purpose other than the In syslen► installaUivn. f_ 5) All septic components must meet*Ti(le V sI pecilications. G) Parking shall not be eonsiructed over I I I O septic conipvneuts. 7) 'I lie property is bounded by properly corners and property lines. L OCAT I Oil MAI' 8) '1'lie property owner shall review design cousidi > )rove cl n eratons to a1 I � Mal C design flow and number of bedronius to be considered Ivr design. Receipt 1( of payment Ibr the plan and inslallalioit based vu the lalan shall be deemed M approval of the design flow by the owner. M 9) 'Hie existing leaching or cesspools shall be pumped and filled with nui(erial per'fille V abandonment procedures. Those williin (Ile proposed SAS shall be removed along with contaminated soil and replaced with clean sand per r HOC V specs. 10)System components to be 10 fleet li-oii: water line. Sewer lilies cifossing the ` T water line shall be sleeved with ,l iucli SC1I CIO PVC with ends gi4outed if' applicable. '1'Iie proposed SAS is being installed below the waleI". -vice SEPTIC SYSTEM I h� nJ 1 G1J line. The lice is to be sleeved as aliireu:enlioiied and main(ained"in place. ' 1 1) If a garbage grinder exists it is to be removed and is lf:c respoi:sibilily of the -- —._. FLOW EST I MATE i i owner to ensure such. � � 'Y---y 12)'Fhe installer is to take caution in excav"ition around (lie gas line ifsuch I 1 exists. Q"� J ~� BEDROOMS AT 11D UAL/DAY/DED11001d - GAL/DAY �3) the installer shall verily the Ivcation, quantity and elevation vl Ilse server i lines exiting the dwelling prior to the installation. I SEPTIC TAiJIt I�I)'I'his plan is representative only (ha( a syslen: cull lit vn a properly niceting ( Dille V requirements. �GAUDAY x 2 DAYS GAL USE � ( GALLON 5EP,TIC T[lAIJIt , A SOIL A(-S011f" T I Ot) SYSTEM r � r6DL 6vy� SON ' r SIDE AREA:01 BOTTOM AREA: �___S E P T I C S Y S'iT ` SEC-1- 1011 �f VA P4 f jfi-------- �� `.�.---�-- O UAL �J J AEI?2 "[G� � �� PEI � � � Q A/ �)0 0 ` � � � s- SEr'TIC TAiJIC f � I- J n �� 9 ✓ - SITE AMU \ LOCA"i' I ON : Ca� h 131IF-PARED FOR : �4q Hi scnL )I�C CNV l DAY I 1�1ASUI�J,1�,� L 110111v1EIJ TAL DLS I UI\lS uA1 t_ �, --- ------ - -� I:.Aa i �Ai�II)Y� I CI I . iv1A z � 11EAL�I 11 nc�El I r ( 5 0 U l f�3 3- 2 17 7 DATE - ._ z w I