HomeMy WebLinkAbout1539 HYANNIS ROAD UNIT UNIT 1539 - Health 15 3 9 Hyannis Rd
Barnstable
A=298 - 008 10B
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No. / Fee
-w THE COMMONWEALTH OF MASSACHUSETTS
Entered in computer: V
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
ZlppYication for ligpogar 6p6tem Con0truction Vermtt
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon 00 ❑.Complete System ❑Individual Components
Location Address or Lot No. 15J C, � sV,s 1� ov,s Narr%e,Address,and Tel.No.
Assessor's Map/Parcela►
cel .�
reakk �e L�tl1ay�e �r
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
-DoLLX COW
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Type of Building:
DwellingNo.of Bedrooms :2_ Lot Size sq.ft. Garbage Grinder
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterati ns(Answer when applicable) I�
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 by thi r f Health.
Signe Date ` G
Application Approved by Date
Application Disapproved by: Date
for the following reasons
Permit No. Date Issued
. No. � a Fee r�
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
application for �Bitpo!gal.6p! tem Con0truction Permit
Application for a Permit to Construct( ) Repair O Upgrade( ) "Abandon( ❑.Complete System ❑Individual Components
- t
Location Address or Lot No.15 3 C1 1� OAr's Name,Address;and Tel.No.
a
Assessor's Map/Parcel .�
�rrsttAb�e l�<«a�� rt�n)
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
1�3c0,0 1�)
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder ( )
to
Other-,_..,,,;. Type of Building, No.of Persons Showers( ) Cafeteria( )
r _ ,r.:
Other Fixtures
Design Flow(min.required) gpd Design flow provided gpd
" Plan Date Number of sheets Revision Date
Title �.
Size of Septic Tank Type of S.A.S. '
Description of Soil
ature of Repairs or Alterations(Answer when applicable) 4
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
,raccordance 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 by this oar f Health. r
` G
Signe /% Date
Application Approved by Date " //0/
,..n Application Disapproved by: Date
for the following reasons
r
Permit No. Date Issued
THE COMMONWEALTH OF MASSACHUSETTS .
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired ( ) Upgraded
Abandoned X by , (. 7� 1�, r,M„t? is
at 1 S / has been constructed in accordance
with the provisions"I Title 5 and the for Disposal System Construction Permit No. :qWdated
Installer ,�i Designer
#bedrooms V -) Approved desi x ow gpd
The issuance of this permit shall not be o,strued�as arantee that the system wi unlhon as de wed C
Date -�- �_- Inspector
No. Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION—BARNSTABLE, MASSACHUSETTS
Oi5po5al *p5tem Construction Permit
Permission is hereby granted to Construct ( ) Repair ( ) Upgrade ( ) Abandon �y )
System located at / � .���.,.,�� s e,
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.
Provided: Construction must be completed within three years of the date of this
Date - G —0-7 Approved by.
,may ,r ., ,s. J, {• i�` ? f
Barnstable Assessing Search Results Page 1 of 2
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Home: Departments:Assessors Division: Property Assessment Search Results
New Search Tr = New Interactive Maps
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Owner: 2007 Assessed
Values:
DONALDSON, MICHAEL A&
JESSICA T
1539 HYANNIS ROAD Appraised Value.Assessed Value
Map/Parcel/Parcel Extension Building Value: $92,600 $92,600
298 /008/106 Extra Features: $0 $0
Outbuildings: $0 $0
Mailing Address Land Value: $148,800 .$ 148,800
DONALDSON, MICHAEL A&
JESSICA T
%WELLS FARGO BANK NA TR Totals $241,400 $241,400
MASTR ASSET BACKED
SECURITIES
1015 10TH AVE SE
MINNEAPOLIS, MN. 55414
2007 REAL ESTATE Tax Information: Tax Rates: (per$1,000 of valuation)
Community Preservation Act Tax $25.78, Fire District.Rates Town
Barnstable-All Classes $2.10 $6.32
C.O.M.M. -.All Classes $1.03 Commei
Barnstable FD Tax(Residential) $506.94 Cotuit FD-All Classes $1.34 $5.57
Hyannis-Residential $1.54 Persona
Town Tax(Residential) $859.34 Hyannis-Commercial $2.37 $5.57
;Hyannis-Personal $2.37 Other Ri
W Barnstable-Residential $2.02 Commur
W Barnstable-Commercial $1.69
W Barnstable-Personal $1.69
Total: $1,39206
C®nstructi®t1 Details Property Sketch Legend
Building Property Sketch & ASI
Building value $92,600 Interior Floors Hardwood
Style Condominium Interior Walls Plastered
Model Res Condo Heat Fuel Gas
http://www.toWn.bamstable.ma.us/assessing/assessO6/displayparcelO7map.asp?mappar=298... 7/9/2007
Barnstable Assessing Search Results Page 2 of 2
Grade Below Average Heat Type Hot Water
Stories 1 Story AC Type None
Exterior Walls Wood Shingle Bedrooms 2 Bedrooms
Roof Structure Gable/Hip Bathrooms 1 Full
1��;;H� %'�f`il3HPYff13�i TilY�3T�l � 3 V
Roof Cover Asph/F GIs/Cmp living area 840f��'� � �f
Replacement Cost $117239 Year Built 1954
Depreciation 21 Total Rooms .4 Roomsi £-t
Landv.
e .wur
CODE 1020
Lot Size(Acres) 0.37
Appraised Value $ 148,800
AsBuilt Card N/A
Assessed Value $ 148,800
View Interactive Maps >
Sales History:
Owner: Sale Date Book/Page: Sale Price:
DONALDSON, MICHAEL A&JESSICA T Jul 24 2003 12:OOAM 17322/022 $ 1
DONALDSON, ROBERT ET AL Sep 14 2001 12:OOAM 14232/004 $100
Extra Building Features
Code Description Units/SQ ft Appraised Value Assessed Value
Property Sketch
Legend
BAS First Floor, Living Area FST Utility Area(Finished Interior) UAT Attic Area(Unfinished)
BMT Basement Area(Unfinished) FTS Third Story Living Area(Finished) UHS Half Story(Unfinished)
CAN Canopy FUS Second Story Living Area UST Utility Area(Unfinished)
(Finished) -
FAT Attic Area(Finished) GAR Garage UTQ Three Quarters Story
(Unfinished)
FCP Carport GRN Greenhouse UUA Unfinished Utility Attic
FEP Enclosed Porch PTO Patio UUS Full Upper 2nd Story
(Unfinished)
FHS Half Story(Finished) SFB Semi Finished Living Area WDK Wood Deck
FOP Open or Screened in Porch TQS Three Quarters Story(Finished)
http://www.town.bamstable.ma.us/assessing/assess06/displayparcelO7map.asp?mappar=298... 7/9/2007
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Town of Barnstable
o Regulatory Services
Thomas F. Geiler, Director
* BAMSTABLE. • .
9. ,. Public Health Division
Thomas McKean,Director
200 Main Street,Hyannis, MA 02601
Office: 508-862-4644 i Fax: 508-790-6304
June 18, 2007
New England Group
4 Cocasett Street
Foxborough, MA 02035
Re: 1539 Hyannis Road
ORDER TO COMPLY WITH STATE ENVIROMENTAL CODE, TITLE 5
The septic system located at 1539 Hyannis Road,Hyannis, MA was last inspected on
May 2"d,2007 by James M. ford a certified inspector for the State of Massachusetts.
The inspection of the septic system showed that the system "Failed"under the guidelines
of 1995 TITLE 5 (310 CMR 15.00) due to the following:
Single cesspools automatically fail in the Town of Barnstable
You have 2 years from the date of the system failure to bring the system into compliance.
If there are any questions about this reminder,please feel free to contact.the Barnstable
Health Department.
B ABLE HEALTH DEPARTMENT
Thomas A. McKean, R.S., C.H.O.
Agent of the Board of Health
COMIVI0NWEALTH OF MASSACHUSETTS
ExEc TIVE OFFICE OF EN IRON�i IFNTA-L AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION 029� /D
Property Address:
Owner's Name:/lieu,
Owner's Address:
G (�
Date of.Inspection:
Name of Inspector: (please rint)
Company Name:
Mailing Address: :.4v rAydu
Telephone Number:
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true, accurate and complete as of the time of 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(3I0 CMR 15.000). The system:
Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspeetor's na Sigai ire:- Date:
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board o ealth ors
DEP)within 30 days of completing this inspection. If the system is a shared system or has a design floNF6 10,0t2
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional oific of the 77
DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable, and the a province
authority, _...__ _ rn
Notes and Comments _
4�,/ lzellw
****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.
x
Page 2 of 1 1
OFFICIAL INSPECTION FORD—NOT FOR VOLUNTARY ASSESSMENT'S
SUBSURFACE SEWAGE DISPOSAL, SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: /
Owner
Date of Inspection: 7
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section
A. Sy:4m Passes:
,(/I have not found any information which indicates that any of the failure criteria described in 310 CNIR
15.363 or in 310 CN1R 15.304 exist.Any failure criteria not evaluated are indicated below.
Comments:
i
1 .
/
f
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"aw determiner"please
explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally
un ound,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 etal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indica ing that the tank is less than 20 years old is available.
D exp a N in:
bservation 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 distrt�on box.System will pass imspectitm if(with
approv of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distnbutm box is leveled or replaced
ND xp atn:
The system required pumping more than 4 times a year due to broken or obstrixied p*(s).The stem will
p s inspection if(with approval of the Board.of.laalth�
broken pipe(s)am replaced
obstruction is removed
ND explain.
2
Paae 3 of l 1
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: S ram- JifS C�
Owner: ror>f�
Bate of Inspection: _�7/�2
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 Zo 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:
r -- Cesspool or privy is within 50 feet of a surface water
r� Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t
f •
2. System will fail unless the Board of H ealth.(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 I 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
I
"This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform
1; bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
l 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:
I :
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Paue 4 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSIVENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: �S �rpii�JIJS �
Owner:Date of Inspection:
D. System Failure Criteria applicable to all systems:.
You must indicate"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 '/day flow
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
of tunes 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 feat 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.]
(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 Systems:
To be considered a large system the system must serve a facility with a design now of 10,0 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 sty dinkingwwzr supply
the system is located in a nitrogen sensitNe area(IntiErim Wed Protection Ares:—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 SeCtian d3 shall upgrade the system in accordance with 310 CUR
15.304. The system owner should contact the appropriate regional office of the Department.
4
Page 5 of l 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: /S Z iLa-4i9l<
Owner: iGC/vi-i�y
Date of Inspection: S E
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
Yes/moo
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 ?
H -the system received normal flows in the previous two week period ?.
_ Ha.e large volumes of water been introduced to the system recently or as part of this inspection?
/ Were as built tans of the system obtained and
p y 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
le
Existing information.For exam plan at the Board of Health.— P a p �
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
0
Page 6 of I I
OFFICIAL.INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL'SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: Nr�iS �
1�
Owner:
Date of Inspection: S
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design):" Number of bedrooms(actual):
DESIGN flow based on 310 CMI�15.203 (for example: 110 gpd x#of bedrooms):
Number of current residents. (�
Does residence have a garbage grinder(yes or no):
Is laundry on a separate sewage system(ys or no): if yes separate inspection required]
Laundry system inspected(ye or nor
Seasonal use: (yes or no��
Water meter readings, if av ilpble(last 2 years usage(gpd)): .
Sump pump(yes or no): 7
Last date of occupancy:
COMMERCIALIINDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): epd
Basis of design flow(seats/persons/sgtetc.):
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:
Was system pumped as part of the inspection(yes or no):
If yes, volume pumped: gallons--How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
Septic tank,distribution box,soil absorption system
oSingle cesspool J
verflow cesspoolhv
—ivy
Shared system(yes or no)(if yes,attach previous inspection records,if any)
_Innovative/Alternative technology.Attach a copy.of the current operation and maintca a contract(io l
obtained from system owner)
Tight tank _Attach a copy of the DEP app inval
Other(describe):
Approximate age of all components,date installed� (if known)��of information:
4 <4/`24E
Were sewage odors detected when arriving at the site(yes or no):,�j�"
Page 7ofII
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE.DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address
Owner: /1//�� ✓a�.,�
Date of Inspection:
BUILDING SEWER(locate on site plan)
Depth below grade: !�
Materials of construction: cast iron _40 PVC_other(explaip.
Distance from private water supply well or suction line:
Comments(on conditi in of joipts,ventin ,evidence of leakag�etc.):
SEPTIC TANK: ocate 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 a Certificate of Compliance(yes or no):—(attach a copy of
certificate)
Dimensions:
Sludge depth:
Distance from top of sludge to bottom of outlet tee or battle:
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 were dimensions determined:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert, evidence of-leakage,etc.):
GREASE TRA .—(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:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert, evidence of leakage,etc.):
7
r
Page 8 of 1 l
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY'ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner: ltllz - z,.,-op,<
Date of Inspection: _5-24le
TIGHT or HOLDING 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:txof
present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:
Comments(note if box is ievci and distribution to outlets equal,any evidence of solids carryover, any evidence of
or rlut ofl ox,etc.):
PUMP C- AM&;ER; (locate on site plan
m we,A'irto ordpr'iyes or o1: _ -
W
I_,V11llllelll..`i 1,l1VlG Condition 01 f3L'iilp{.lidi L•bwi,bVl/uliivu V■ .::ii Fi3 ysl.•++••••++++'
G
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Page 9 of I I
OFFICIAL INSPECTION FORM—,NOT FOR VOLUNTARY ASSF
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ORM
PART C
SYSTEM INFORMATION(continued) I
Property Address:
c �
Owner: G �D�
Date of Inspection:
SOIL ABSORPTION SYSTEM(SAS):) (locate on site plan,excavation not`required)
If SAS not located explain why:
Type
leaching pits, number:_
leaching chambers,number:
leaching galleries,number:
leaching trenches,number, length:
leaching fields,number,dimensions:
overflow cesspool,number:
innovative/alternative system Type/n a of technology:
Comments(note condition of soil,
etc.): signs of ydraulic failure,level'of—pond—in—g,damp soil,condition of vegetation,
CESSPOOLS:Alfc:spool must be p ped as art of ins p pection)(locate on site plan)
Number and configuration:
Depth—top of liquid to isle invert:
Depth of solids laver: --�— j
Depth of scum layer: 1
1
Dimensions of cesspool: -
Materials of c �
onSfSitCtton:
Indication of groundwater inflow(yes o o):
Comments(note condition of soil,signs of y
_ , eve of ponding,condition of vegetation,etc.): 1
PR v Y: (locate on site plan)
Materials of construction:
fl�mA�S:CnS:
Depth of solids:
Corr.meJ 5(Jute:'ore itic: Gf s.�:t cif ofuydrauc
aiure, level ofl i
x
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Page I I ofi I
OFFICIAL, INSPECTION FORM—NOT FOR VOLUNTARY ASSES
SMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner:
Date of Inspection: S 7
SITE EXAM
Slope Yate;,.,,eo /✓'�
Surface ell-
Check cellar
Shallow wells
Estimated depth to ground water feet
Please indicate(check)all methods used to determine 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 S)
_,'--thecked with local Board of Health-explain: ����-
Checked with local excavators, installers-(attach documentation)
Accessed US database-explain:
You must d cr*be how you established the high ground wat r elevation:
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