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TOWN OF BARNSTABLE
LOCATION Y3 ` f€ �n SEWAGE # q7-7o
VILLAGE C.UuwtI,A&MU(� ASSESSOR'S MAP & LOT t7
INSTALLER'S NAME&PHONE NO. tu-/3 TiIZ03 C 'l, 3foa2—6 a3
SEPTIC TANK CAPACITY O �r
LEACHING FACILITY: (type) 3 S X 65n�- size) X 33 T a FEcv,
NO.OF BEDROOMS
BUILDER OR OWNER &YEY 4IV 6$?A 514fi O
PERMITDATE: l —/L_ - COMPLIANCE DATE: /Z /5-
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
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US Postal Service
Receipt for Certified.Mail
No Insurance Coverage Provided.
Do not us for International Mail See reverse
Sent to
t Number
Po ice,State,&ZIP Code
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Postage
Certified Fee
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Restricted Delivery Fee
rn Return Receipt Showing to
Whom&Date Delivered
n Retum Receipt Showing to Whom,
Q Date,&Addressee's Address
O TOTAL Postage&Fees $ 77
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Postmark orDate /`�7
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Stick postage stamps to article to cover First-Class postage,certified mail fee,and
charges for any selected optional services(See front).
1. If you want this receipt postmarked,stick the gummed stub to the right of the return
address leaving the receipt attached, and present the article at a post office service
window or hand it to your rural carrier(no extra charge). E2
2. If you do not want this receipt postmarked,stick the gummed stub to the right of the
return address of the article,date,detach,and retain the receipt,and mail the article.
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3. If you want a return receipt,write the certified mail number and your name and address
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RETURN RECEIPT REQUESTED adjacent to the number. Q
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addressee,endorse RESTRICTED DELIVERY on the front of the article. 0
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5. Enter fees for the services requested in the appropriate spaces on the front of this
receipt. If return receipt is requested,check the applicable blocks in item 1 of Form 3811. li
6. Save this receipt and present it if you make an inquiry. 102595-97-B-01 45 a
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cNo. 9 7— /0� � 0 t r Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS
0(pprication for Digogaf *pgtem Con5tructiou Permit
Application is hereby made for a Permit to Construct( )or Repair('/)an On-site Sewage Disposal System at:
Location Address or Lot No. Own ' Name,Address el.No.
A-AAYS*A& he J
Installer's Name,Address,and Tel.No. ��� "�— Designer's Name,Address and VrNo.
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Type of Building:
Dwelling No.of Bedrooms_ Garbage Grinder
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow�� gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Desc 'ptiofi-o oil '�
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tore of Repairs or Alteration (Answer whe applicabl- !A
44
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Date last inspected:
Agreement:
The undersigned agrees to ensure the onstruction and maintenance of the afore described on-site sewage disposal system
in accordance with the pro 'sions of JW of the Environmental a and not to place the system in operation until a Certifi-
cate of Compliance has be ss y this Board of Health. -/9—�
Signe Date
Application Approved by
Application Disapproved for the following reasons
Permit No. / 7' l o r Date Issued 7
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No. 9/ `70 " " '...r `� ' -.:» Fee
`T THE COMMONWEALTH OF MASSACHUSETTS -
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLES MASSACHUSETTS y.
2pplication for Mi5pogaf *p!tem Cougtruction Permit �a ,
Application is hereby made'for a Permit to Construct( )or Repair(r)an On-site Sewage Disposal System at:
Location Address or Lot No. f Owne ' Name,Address a d Fel.No.
AA)5 AV4 .
Installer's Name,Address,and Tel.No. Designer's Name,Address and e.No.
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Type of Building:
Dwelling No.of Bedrooms Garbage Grinder
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow i3 gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Desc 'ption of SoAla
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1�1 ture o e airs or Alterations(Answer whe applicanl- /��� -5� -
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Date last inspected:
Agreement:
The undersigned agrees to ensure th3f onstruction and maintenance of the afore described on-site sewage disposal system
in accordance with the pro isions of T' 5 of the Environmental qde and not to place the system in operation until a Certifi-
cate of Compliance has be ss d- y this Board of Health.
Signe Date G f
Application Approved by
Application Disapproved for the following reasons
Permit No. / 7- Date Issued Z _ Z- / 7
AT THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CE TIFY,that the On-site Sewage Disposal System installed( )or repaired/replaced(/' )on
by L.,r ! iZAS•Gv it S YL for
as has een constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. ?7-; � dated
Use of this system is conditioned on compliance with the provisions set forth below:
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No. Fee ✓� ��
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
Mi5pozar *patent Cottgtruction Permit
Permission is hereby granted to
to construct( )repair( )an On-site Sewage System located at3 'S�f � d y �"''✓`ZJ'
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: 12 "/2 - S 7 Approved
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I0N197
NOTICE: This Form Is To Be Used For the Repair Of Failed
Septic Systems Only.
CERTIFICATION OF SKETCH AND APPLICATION(WITHOUT
DISPOSAL WORKS CONSTRUCTION PERMIT
ENGINEERED PLANS)
,
hereby certify that the application for disposal works
constructi permit signed by me dated ,Z`—` `-` V ,concerning the
property located at � `�''
CU �>sd meets all of the
following criteria:
Jw • There are no wetlands located within 100 feet of the proposed leaching facility
l(N . There are no private wells within 150 feet of the proposed septic system
hJ . There is no increase in flow and/or change in use proposed
There are no variances requested or needed.
If the proposed leaching facility will be located within 250 feet of any wetlands,the bottom of the
proposed leaching facility will uQJ be located less than fourteen(14)feet above the maximum adjusted
groundwater table elevation.
Please complete the following:
A)Top of Ground Elevation(according to the Engineering Division G.I.S.map)
B)Observed Groundwater Table Elevation(according to Health Division well map)
SIGN
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� DATE:
LICENSED SEPTI YSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER
[Attach a sketch plan of the proposed system.Also If the licensed Installer posesses a certified plot plan,
this plan should be submitted].
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TOWN OF BARNSTABLE �v
LOCATIONS SEWAGE # 47-�
:: I AGE C'.Uu1I,v►&bj ASSESSOR'S MAP & LOT`
-.INSTALLER'S NAME&PHONE NO. C�(-i S filty5 C•oA097 36,a—6 R
`;$)✓PTIC TANK CAPACITY /S'o O
HING FACILITY: (type) 3 S X Xa2 `. size) /3 ,X 33�a X
zNO;OF BEDROOMS
';BLIII DER OR OWNER—(.9tY A 160?4 59)t O
COMPLIANCE DATE: LZ- IS 9 7
`.*paration 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
of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
'Fvr�ished by
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Town of Barnstable
Department of Health, Safety, and Environmental Services
himPublic Health Division
039. A P.O. Box 534,Hyannis MA 02601
Office: 508-790-6265 Thomas A.McKean,RS,CHO
FAX: 508-790-6304 Director of Public Health
November 7, 1997
Mr, Gary Andrashko
4351 Route 6A
Cummaquid, MA 02637
ORDER TO COMPLY WITH 310 CMR 15.00, THE STATE ENVIRONMENTAL
CODE TITLE 5.
The septic system owned by you located at 4351 Route 6A, Cummaquid was inspected
on October 20, 1997 by David Coughanowr a Massachusetts licensed septic inspector.
The inspection of your septic system showed that your system has failed under the
guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following:
• Backup of sewage into facility or system component due to an overloaded or
clogged soil absorption system.
You are directed to hire a licensed professional engineer(PE)to design a system that will
bring the septic system in compliance with 310 CMR 15.00, The State Environmental
Code, Title 5 within twenty-one (21) days of your receipt of this letter.
You are also directed to hire a licensed septic system installer to install the system
components within forty-five (45) days of your receipt of this order.
You are further directed to maintain the system by hiring a licensed septage hauler to
pump the septic system to prevent discharge of sewage or effluent into the buildings, onto
the surface of the ground, or in to surface waters.
Any person aggrieved by any order issued by the local approval authority may appeal to
any court of competent jurisdiction as provided for by the laws of the Commonwealth.
PER ORDER OF HE BOARD OF HEALTH
Thomas A. McKean, R.S., C.H.O.
Agent of the Board of Health
Town of Barnstable
• Department of Health, Safety, and Environmental Services
tea"MM&� Public Health Division
t639.
A 367 Main Street, Hyannis MA 02601
Office: 508-790-6265 Thomas A.McKean,RS,CHO
FAX: 508-790-6304 Director of Public Health
TO: _ 66r 41ziroff4i W (�
351 ou�.2 (0a DATE: �Cdt,�Z
A
ORDER TO COMPLY WITH 310 CMR 15.00, THE STATE ENVIRONMENTAL
CODE, TITLE 5.
The septic system owned by you located at 1/36/ Ca,►ArnaG u'�cA_
was inspected on 6c4o�zo,i221 by CouyL,,�ow- a Massachusetts licensed
septic inspector.
The inspection of your septic system showed that your system has failed under the
guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following:
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of- c j ? A: o.'%
You are directed to hire a licensed professional engineer (PE) to design a system that will
bring the septic system in compliance with 310 CMR 15.00, The State Environmental
Code, Title 5 within twenty-one (21) days of your receipt of this letter.
You are also directed to hire a licensed septic system installer to install the system
components within forty-five (45) days of your receipt of this order.
You are further directed to maintain the system by hiring a licensed septage hauler to
pump the septic system to prevent discharge of sewage or effluent into the buildings, onto
the surface of the ground, or in to surface waters.
Any person aggrieved by any order issued by the local approval authority may appeal to
any court of competent jurisdiction as provided for by the laws of the Commonwealth.
PER ORDER OF THE BOARD OF HEALTH
Thomas A. McKean, R.S., C.H.O.
Agent of the Board of Health
gV=dthWbfile0LWe5edoc
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ASSE °^RS MAP NO: CS
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PAR%4 L.1s•.11J:
ECO-TECH 00r 2
ENVIRONMENTAL TowNo, 319g
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THIS FORM IS A FACSIMILE OF THE STANDARD SEPTIC INSPECTION FORM ISSUED BY THE MASS SETTS T.
DEPARTMENT OF EN IRONMENTAL PROTECTION (revised 4/25/97)
3 ®-o JC SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM , ,G �
PART A
CERTIFICATION
Property Address: 4351 Route 6A,Cummaquid Address of Owner
Date of Inspection: October 17, 1997 (If different)
Name of Inspector:David D.Coughanowr,R.S.
I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000)
Company Name Eco-Tech Environmental
Mailing Address 43 Triangle Circle Sandwich,MA 02563
Telephone Number (508) 888-0185
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 funct[ n and maintenance of on-site sewage disposal systems.The system:
Passes �-�H OF/aqS
Con ► asses s�'n
Ne erUaTfliado Local Approving Authority
1 N
_�Fa' UG JR
Inspector's Signature Date:
Inspector's Note=_> A se s�C�STtiQVatepd
ss this Real Estate Transfer Inspection if it does not trigger
p mv� r+ , p gger any of the failure
criteria listed below.The septic sys according to the conditions observed on the day it was inspected.No estimate
or guarantee of system longevity is ma a i' ed by a passing determination.
The System Inspector shall submit a copy of this report to the local 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:
A] SYSTEM PASSES:
1 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.
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 ND).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 exfiltradon,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.
i
SUBSURFACE.SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 4351 Route 6A
Owner: Gary and Faye Andrashko
Date of Inspection: October 17. 1997
B] 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).Describe observations:
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled 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 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
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 to 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 1 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)
3) OTHER
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 4351 Route 6A
Owner: Gary and Faye Andrashko
Date of Inspection: October 17. 1997
D) SYSTEM FAILS:
You must indicate either"Yes"or"no"to each of the following:
X 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
deternine what will be necessary to correct the failure,
Yes No
x _ Backup of sewage into facility or system component due to an overloaded or clogged
SAS or cesspool.
�L Discharge or ponding of effluent to the surface of the ground or surface waters due to
an overloaded or clogged SAS or cesspool.
_X_- 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 1/2 day flow.
X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped_
X Any portion of the Soil Absorption System,cesspool,or privy is below the high groundwater elevation.
X Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
X Any portion of a cesspool or privy is within a Zone 1 of a public water supply well
X Any portion of a cesspool or privy is within 50 feet of a private water supply well
X 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:
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:
The system serves a facility with a design flow of systems 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-
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.
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 with the local regional office of the Department for further
information.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 4351 Route 6A
Owner: Gary and Faye Andrashko
Date of Inspection: October 17. 1997
Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following:
Yes No
X _ Pumping information was provided by the owner,occupant or Board of Health.
X _ None of the system components have been pumped for at least two weeks and the system
has been receiving normal flow rates during that period.Large volumes of water have not
been introduced into the system recently or as part of this inspection.
JILa- _ As built plans have been obtained and examined. Note if they are not available with N/A
X _ The facility or dwelling was inspected for signs of sewage backup.
X — The system does not receive non-sanitary or industrial waste flow.
The site was inspected for signs of breakout.
including
All system components,excludin the Soil Absorption System.have been located on the site.
primary cesspool primary cesspool
The septic tank manholes were uncovered,opened,and the interior of the septic-tapk was inspected for
condition of baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge,depth
of scum.
The facility owner(and occupants,if different from owner) were provided with information on the proper
maintenance of Sub-Surface Disposal System.
The size and location of the Soil Absorption System on the,site has been determined based on:
existing information.Ex.Plan at B.O.H.
Determined in the field(if any of the failure criteria_ related to pan C is at issue,approximation of
distance is unacceptable) [15.302(3)b)]
I •
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 4351 Route 6A
Owner: Gary and Faye Andrashko
Date of Inspection: October 17. 1997
FLOW CONDITIONS
RESIDENTIAL-
Design flow:-nLa-g.p.d/bedroom for S.A.S.(design plan not available at BOH)
Number of bedrooms: 5
Number of current residents-2-
Garbage grinder(yes or no): no
Laundry connected to system (yes or no):yes
Seasonal use(yes or no):no
Water meter readings,if available(last two(2)year usage(gpd): 1995-1996: 39,000 gallons
1996-1997:37,000 gallons
Sump Pump(yes or no): no
Last date of occupancy: currently in a state of intermittent occupancy)
COMMERCIAL/INDUSTRIAL:
Type of establishment-
Design flow: gallons/day
Grease trap present: (yes or no):
Industrial Waste Holding Tank present: (yes or no-
Non-sanitary waste discharged to the Title 5 system: (yes or no):
Water meter readings,if available:
Last date of occupancy:
OTHER: (describe):
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
First cesspool (not septic tani) pumped approXmately 4 years a¢o(Owner)
System pumped as part of inspection (yes or no) No
If yes,volume pumped: gallons
Reason for pumping.
TYPE OF SYSTEM:
X Septic tank/disvibudewbox/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system (yes or no) (if yes,attach previous inspection records,if any)
I/A Technology etc.Copy of up to date contract?
Other
APPROXIMATE AGE of all components,date installed(if known)and source of information.
System age unknown.Dwelling_constructed in mid 1800s.System appears to have been upgraded several
times in the interim No information available at Board of Health
Sewage odors detected when arriving at site: (yes or no) no
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 4351 Route 6A
Owner: Gary and Faye Andrashko
Date of Inspection: October 17. 1997
BUILDING SEWER: Building sewer could not be inspected-no access provided at foundation,
(Locate on site plan)
Depth below grade:
Material of construction_cast iron _40 PVC_other(explain)
Distance from private water supply or suction line
Diameter
Comments: (condition of joints,venting,evidence of leakage,etc.)
SEPTIC TANK: X
(locate on site plan)
Depth below grade: 1 ft.
Material of construction: X concrete_metal_Fiberglass_Polyethylene_other(explain)
If tank is metal,list age_ Is age confirmed by certificate of compliance_(Yes/No)
Dimensions: 8.5'x 5'x5'
Sludge depth: 16„
Distance from top of sludge to bottom of outlet tee or baffle: 18"
Scum thickness: 18"
Distance from top of scum to top of outlet tee or baffle: scum layer has breached outlet tee
Distance from bottom of scum to bottom of outlet tee or baffle: 0
How dimensions were determined: probe to top of tank
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.) Critical time for Dumping long since passed,Tank's effective capacity,
effluent detention time,and solids removal effectiveness have been irretrievably compromised due to lack of maintenance
pumping Black organic sludge was observed at both inlet and outlet covers,indicating backup to ton of tank
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:
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.)
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 4351 Route 6A
Owner: Gary and Faye Andrashko
Date of Inspection: October 17. 1997
TIGHT OR HOLDING TANK: none (Tank must be pumped prior to,or 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
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: none
(locate on site plan)
Depth of liquid level above outlet invert:
Comments:
(note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.)
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.)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 4351 Route 6A
Owner: Gary and Faye Andrashko
Date of Inspection: October 17. 1997
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: 1
leaching fields,number,dimensions:
overflow cesspool,number. 2
Alternative system:
Name of Technology:
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) Effluent exiting
tank flowed into a cesspool constructed of large stones,overflowed into a block pit.An Orangeburg pipe led from there
to what appeared to be a leaching trench.Both the cesspool and the pit were over 2/3 full System appears to have been
repaired at successive intervals in the past
CESSPOOLS: X_
(locate on site plan)
Number and configuration: One np•mary and one overflow pit(described abovel
Depth-top of liquid to inlet invert: 1 1"and 16"
Depth of solids layer: 6" &3'
Depth of scum layer: trace
Dimensions of cesspool: 6 ft x 6 ft(approx)
Materials of construction: Large rocks and concrete block
Indication of groundwater none
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: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.)
I
f
t
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 4351 Route 6A
Owner: Gary and Faye Andrashko {
Date of Inspection: October 17. 1997
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include des to at least two permanent references,landmarks,or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
LOCATIONS
A B
1 19.5 ft 31 ft
2 18 ft 26.5 ft
GARAGE 3 24.5 ft 29.5 f t
113 Al 4 31.5 ft 25.5 ft
5 39 ft 32 ft
t
SEPTIC
20 o TANK
5 BEDROOM
LEACH DWELLING
PIT
APT" 3 ,/ # 4351
4
s
I
LEACHING
TRENCH I z
J
Iw I
3
ROUTE 6A
NOT TO SCALE
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 4351 Route 6A
Owner: Gary and Faye Andrashko
Date of Inspection: October 17. 1997
Depth to groundwater: 10+ feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
Observation of Site(Abutting property,observation hole,basement sump,etc.)
Determine it from local conditions
Check with local Board of Health
Check FEMA Maps
Check pumping records
Check local excavators,installers
X Use USGS Data
Describe in your own words how you established High Groundwater Elevation. (Must be completed)
Comparison of USGS Topography maps and surface water elevation data.
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