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HomeMy WebLinkAboutMiscellaneous - 124 ROCKY BROOK ROAD 4/30/2018 ,r77 124 ROCKY BROOK ROAD ;oad '- 210/09O.A-0056-0000.0 j MAP # LOT # _ PARCEL # STREET . - ONSTRUCTI.ON�APPROVAL HAS PLAN REVIEW FEE BEEN PAID? YES NO PLAN APPROVAL:, DATE APP. DESIGNER 0'-3oczb PLAN DA I E:_� CONDITIONS -- WATER SUPPLY: OW WELL (�T WELL PERMIT DRILLE R._... ...____..____..__..._...__._._._..:_._......._.._._-- WELL TESTS: CHEMICAL DAL E APPROVED.___..._._:_._- BACT A I DA I E flPPRUVED BACTERIA DATE APPRUVED__.._.__._- COMMENTS FORM U APPROVAL: APPROVAL 1'U I5SU - YE5 NO DATE ISSUED / I BY— CONDITIONS: FINAL APPROVAL: . ALL PERMITS PAID NO WELL CONSTRUCTION APPROVAL YES NO SEPTIC SYSTEM CONSTRUCTION APPROVAL YE NO OTHER YES NO ANY VARIANCE NEEDED YES NO FINAL BOARD OF HEALTH APPROVAL: DATE:....... ....._._._._ to ti =x IS THE INSTALLER LICENSED? YE NO iti 1. r�.w^.•:h • •• vt y ` TYPE. OF'- CONSTRUCTION: ; NEW REPAIR' NEW CONSTRUCTION: CERTIFIED PLOT PLAN REVIEW 'YE NO ` CONDITIONS OF.,APPROVAL YES NO r,;L • , . _' (FROM .FORM U) .,.,;ISSUANCE OF DWC PERMIT f YES NO •-�DWC PERMIT NO. t INSTALLER: • 1 ' BEGIN .INSPECTION YES NO i \. _• _ EXCAVATION . INSPECTION: : NEEDED: PASSED =` HY 4. -<CONSTRUCT.ION INSPECTION: NEEDED: AS BUILT PLAN SATISFACTORY: YES: APPROVAL TO BACKFILL: DATE: BY LLQ .-!,FINAL - GRADING APPROVAL: DATE j i/ I q4— ' BY FINAL CONSTRUCTION APPROVAL: : : DATE. BY ''1''1 .•1• � •. t'. , _ ' ... .• _ . :. .. �1 . ! • •• , Town of North Andover, Massachusetts Form No.2 NORTH BOARD OF HEALTH F w 19_�_ 2 ----• ~ ' DESIGN APPROVAL FOR SSACNUSEt SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM Applicant &rV10<z Test No. Site Location i Reference Plans and Specs. ENGINEER DESIGN DATE Permission is granted for an individual soil absorption sewage disposal system to be installed in accordance with regulations of Board of Health. CHAIRMAN,BOARD OF HEALTH Fee Site System Per No. �� Town of North Andover, Massachusetts Form No.3 NORTH BOARD OF HEALTH • F p �► '��,,:o.�°`� DISPOSAL WORKS CONSTRUCTION PERMIT • 9SSACMUSEt ' Applicant e v'1 < , NAME ADDRESS TELEPHONE n r-� Site Location `7, /`� c;c l _v �� ��u , 1< Permission is hereby granted to Construct, ,\ or Repair ( ) an Individual Soil Absorption Sewage Disposal System as shown on the Design Approval S.S. No. f CHAIRMAN,BOARD OF HEALTH Fee ` D.W.C. No. • i $. Ch W4 - 2 s: FORM u — L®T RELMo PM M INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable local or state law, regulations or requirements. ****************Applicant fills out this section***************** APPLICANT: -� 1., .-�r, 1��� s 1-.• r Phone ls7.-777�/ LOCATION: A=ssessor' s Map Number Parce_ Subdiv,-s lon tom°,� k t Lots; St. Nu.:.ce_r �{ �_. *'�Fzic�c�e*�i�c�c�F�Fic*�iie�kic�t�c�eir�F�iQfilClal Use RECOM-1ENDATIONS OF TOWN AGENTS: Date Attrcved c=,s=__ :a-_cn kd-_nistra-cr Date Rel ecte•d Date Arrrcved Town Penner Date Rej ec-ad Cc en:s Date Attrcved Fccc _^.=Lec- - ealth Date Rej e_-a_ uDate Ab-rcve'd < Sc-r-c _n_zec Dame Re;e�-�_ C c.- ar pu.,__c wcrx sewer/water ccnnea-t-ons - dr'vewa`_ Pe' t Fire Detart..&ent - � Received by Building Inspector Date DATE Sheet of BOARD OF HEALTH TOWN OF NORTH ANDOVER SUBSURFACE DISPOSA/L DESIGN REVIEW FEE PERMIT # DATE RECEIVED APPLICANT ASSESSOR'S MAP ADDRESS PARCEL # ll LOT # � ENGINEER � N c ->6608 STREET ADDRESS PLAN DATE /(v/9 REVISION DATE CONDITIONS OF APPROVAL: APPROVED DISAPPROVED -G � 4:7 i I J 10 CMR: DEPARTMENT OF E1wTRONMENTALP ROTECTION 15.041. continued (2) By January 1, 1998 the Executive Office of Environmental Affairs and the Department shall - issue a report making recommendations based upon the information gathered above and other. relevant materials, which shall provide clear and concise direction for the use of innovative, alternative, clustered and shared on-site sewage treatment anddisposal systems on land not currently buildable. The reports shall contain recommendations,.b:Lsed upon the studies and.information gathered, for amendments to 310'CUR 15.000. By January 1, 1999 the Department shall revise 310 CMR. 15.000 as it deems necessary to implement the recommendations. The Department is committed to increasing the maximum allowable percolation rate to 60 minutes per inch together with the use of soils analysis for new construction as well as the repair of existing systems unless the Department concludes based on the report that this is not appropriate. 15.050• `Sevemuitly The provisions of 310 CMR 15.000 are.severable. If any provision of 310 CMR 15.000 is declared.to be invalid;or inapplicable to any particular circumstance,.that invalidity or inapplicability will"not effect the enforceability of the remainder of 310 CMR 15.000. 15.100' 'General Provisions. 1 (1) Every location proposed for the construction,upgrade,"or expansion of an on-site subsurface sewage disposal system shall be evaluated based upon an analysis of all site characteristics " which may affect system function and performance in accordance with the evaluation criteria specified in3:10CMR 15.101 through 15.07:. . (2) After January 1, 1996, every location (which has not filed for or which does not have a valid disposal works construction permit issued under the 1978 Code) shall be field evaluated for suitability for subsurface sewage disposal consistent with 310 CMR' 15.000 by a Soil Evaluator apprbved by the Department in accordance with 310 CMR 15.018 prior to the commencement of final system design pursuant to Subpart C-of'310 CMR 15,000 and application for a Disposal System Construction Permit. The evaluation shall include a soil profile on every proposed.disposal area for which,a,Disposal System Construction Pernut has not yet been issued:.. 15,101- Soil Faaluation Criten' (1), Every proposed disposal.area shall be examined to determine if the disposal area is compatible with the proposed sewage disposal'system in relation to the design flow set forth in 310 CMR 15.203 and system location criteria set forth in 310 CMR 15.106. (2) Every proposed disposal area shall be assessed based on the following field test and analysis criteria: . (a) deep observation hole testing; (b) soil profile determination; (c) .percolation testing; (d) landscape position;and (e) hydrogeologic properties (3) Soil evaluation may be conducted at any time of the calendar year,provided that the Soil Evaluatormakes and records on the site evaluation form proper consideration of the hydrogeologic properties ofthe specific site as required in 310 CMR 15.107 for the period of the water year within which the evaluation is performed: 15.102' Deep Observation Hole Test (1) The purpose ofthe`deep observation hole testis to determine in accordance with 310 CMR 15.103 the soil profile,in the proposed disposal area, the.depth of overburden above ledge, bedrock or impervious layer(s),and to determine the observed ground-water elevation at the time of testing and to gather evidence to determine the adjusted ground-water elevation. 11/3/95 310 CivM-504 ' ��� r= sg s ,s t r �'3r�� #i. �-.✓�Jr��<t��If�t�� tri ''y a or'Fk rAt tt s -�E a.�� ��.� t i �1 .-- yMAN 4 a ✓' 1 E ��L tht M�r : � Xr" 9 y s� 'C`'�F 7 d"T1 "� .x��p# .� :+yj"� ry rM C r R :. ,'�S'a i.' s•. s .„� � '7a s 1 t rt e a,4s'ra'/ - a ,:: rf e: .�*.r 'l1. �>•,rt c' + :+ III ( I i � 4 ! 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V;A s R V `�e�/t t[� tl�1'6 1 r .t �4 � t \ � - 1 t� t t y ' 7t t !M Ji x tNpt 'W, A\Tr,Ca4�(1:� ,f' tt Y III r• �.. : s� WW Y�x •, 7 Le it o s T r t t jttlSy6^ r , rs.�tyt� <�'bn �` ;, N�W 'EAl4G►�,R�iW' ���5.��,�3J�J�lIGE�S l��.: W♦ J a ii :{ J.. ,� I'•1fM` .sqr ct Y 1 DIVERSIFIED, CIVIL ENGINEERING CERTIFICATI®N " Property-Locati6m Lot 4A Rocky Brook Estates Town/Statec North Andover,Massachusetts DCE Plan,Refere'kei Drawing'Number1028 ,I, Peter G Parent, a Civil Engineer, duly` licensed as such'in.the .Commonwealth' of Massachusetts, do.hereby-certify that I have visually:;inspected the constructed subsurface sewage,dispo"sal system shown on the referenced plan, and furthei certify'that,the system, as constructed, generally conforms, within'acceptable tolerances; to that of.the record design plan, as'referenced on the.As-built plan, and';complies wth-the,regulations set forth in 310 CMR 15:00. OF PETER o G. PARENT ' No.37846 r Peter G:'Parent, P.E. Date:; 359 Littleton Road, Westford, MA 01886, (5.08) 692-0939. P 0. Box 880, Methuen, MA. 01844 (508) 6,87-7161' I V FRED'EI-) Civit., EN( INIE, RING CERTIFICATIO Property Location: Lot 4A Rocky Brook Estates Town/State: North Andover, Massachusetts PCE Plan Reference: Drawing Number 1028 1, Peter G. Parent, a Civil Engineer, duly licensed as such in the Commonwealth of Massachusetts, do hereby certify that I have visually:inspected the constructed subsurface sewage disposal system shown on the referenced plan, and further certify that the system, as constructed, generally confomis, within acceptable tolerances, to that of the record design plan, as referenced on the as-built plan, and complies with the regulations set forth in 31'.0 CMR 15.00. I, IN of MqS 0��� S9CyG PETER G. PARENT No.37846 O S AL ' Peter G. Parent, P.E. Date: e 359 Littleton Road; Westford, MA 01886 (508) 692-0939 P.O. Box 880, Methuen, MA 01844 (508) 68777161 "ORT$, BOARD OF HEALTH + s 120 MAIN STREET TEL. 682-6483 �9S SACH USEt�� NORTH ANDOVER, MASS. 01845 Ext23 August 11, 1994 !�I c New England Engineering Services, Inc. 33 Walker Road, Suite 22 North Andover, MA 01845 Re: Lot #4A Rocky Brook Road Dear Ben: This is ' to inform you that the proposed plans for site referenced above have been disapproved for the following reasons: 1) Benchmark should be nearer system. 2) Need manhole to grade on tank. 3) No perc at bottom of system. 4) Please show trench dimensions on site plan. If you have any questions, please do not hesitate to call the Board of Health Office at the number above. Sincerely, �I Sandra Starr, R.S. Health Administrator SS/cjp I PLAN REVIEW CHECKLIST ADDRESS 9 ' 00f)/BQaoA:1ENGINEER-/t/C-aJ GENERAL 3 COPIES STAMP L� LOCUS C---' NORTH ARROW L/ SCALE CONTOURS J/ PROFILE (/ SECTION C--' BENCHMARK 7 sV5, SOIL & PERC INFO ELEVATIONS WETS. DISCLAIMER L/ WELLS & WETLANDS WATERSHED? A/O DRIVEWAY �Elev) WATER LINE FDN DRAIN l/ SCH40 c-� TESTS CURRENT? SEPTIC TANK MIN 1500GL-'/ . 17 INVERT DROP GARB. GRINDER(+200% EDF) 25 ' TO CELLAR MANHOLE TO GRADE ELEV GW D-BOX SIZE # LINES QZ FIRST 2 ' LEVEL STATEMENT INLET/��,,,�, OUTLET //j3.Sd = �/7 (2" � OR . 17 FT) TEE REQ'D? Ie / 7 lc4'j � LEACHING / MIN 660 GPD? /-// RESERVE AREA 4,-Z4 ' FROM PRIMARY? � 2% .SLOPEf 100 ' TO WETLANDS V 100 ' TO WELLS ✓ 4 ' TO S.H.GW 35 ' TO FND & INTRCPTR DRAINS L,"� 325 ' TO SURFACE H2O SUPP 4 ' PERM. SOIL BELOW FACILITY e� MIN 12" COVER L/FILL?/Vc) (25 ' if- above natural elev; 10 if below) BREAKOUT MET? TRENCHES MIN 660 gpdF� SLOPE (min . 005 or 6"/1001 ) ✓ >31COVER?-VENT�-, SIDEWALL DIST. 2X EFF. W OR D (MIN 6 ' ) ✓ IS RESERVE BETWEEN TRENCHES? � IN FILL? MUST BE 10 ' MIN� 4" PEA STONE?,�,// BOT X LDNG �. + SIDE lb' M X LDNG ;� = TOT I(rri(� (L x W x #) (G ft2) (DxLx2x#) (G/ft2) Copyright© 1993 by S.L.Starr TOM OG WCIRTEe AMQO ER/ COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS SEP 9 199 I' • DEPARTMENT OF ENVIRONMENTAL PROTECT¢hO�''° J ONE WINTER STREET. BOSTON, MA 02108 617-292-5500 .y a , WILLIAM F.WELD TRUDY CORE; n Governor Sccretar);,r ARGEO PAUL CELLUCCI DAVID B.STRUHS Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner s -PART A CERTIFICATION C N�l i lr S W C"/&Jj `I Property Address: ��� t?oP/Cy 6,q0, Address of Owner: I_ 41 Alto vrA 0 18 y <_ Date of Inspection: 13'-2 7'"c1 7 (If different) Name of Inspector: A/-6 R1',A j I am a DEP approjvd.i'.AIrA cAiigioW cW 15.340 of Title 5 (310 CMR 15.000) ;, Company Name: 4W Gma Road LV. Mailing Address: N Daftouff%MA MW Telephone Number: ". F CERTIFICATION ON. y 'i I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate ;i 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 v .. Needs Further Evaluation By the Local Approving Authority I: _ Fails , Inspector's Signature: �Z6(� Date: A 7—r 7 The System Inspector shall submit a copy of this inspection report to the Approving Authoritywithin 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 I 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: .I—S 7-77GLT i/ 1?jPf'T7T'/lt'0(� A] SYSTEM PASSES l s I have not found any information which indicates thauthe system violates any of the failure criteria as defined in 310 CMR 15.303 it l Any failure criteria not`evaluated'are1ndicated below. COMMENTS: Cs: B] SYSTEM CONDITIONALLY PASSES: I Alf) 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. I 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 I Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or Ii. i . 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 conforming septic tank as approved by the Board of Health. i! (revised 04/25/97) Page 1 of 10 DFP on the World Wide Web: http:/twww.magnet.state.ma.us/dep j Printed on Recycled Paper 1 • 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) ' Property Address: n-'f goPk /�ooh f�D. LINO o�/1 /Z a , Owner: C#11 el rl?S IAJ e HetS tZ J/l. Date of Inspection: X_a 7— 9 7 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 or uneven distribution box. The system will ass inspection if (with approval of the a r to a broken settled e p Pe P iesodueY PP Board of Health). Describe observations: tl. 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 o$�3 gc ;' obstruction is removed .3i4lDn 14ALe"Aa fi41 ' f (' rl+oJ0 ANI ,tit M C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: T.' Di Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protea 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 t` WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: t: 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: t sv _ The system has a septic.tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply ors4{ 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 z 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). I.. 3) OTHER kr'.. �i P . f- j i r (revised 04/25/97) Page 2 of 10 iA[ a 1 ;t ; i i ;' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ;;• PART A it CERTIFICATION (continued) Property Address: /a R of/C y IJ R ooK RV),, A), Owner: G�l�tF7�+ u1�('.ffr31�E jr? Date of Inspection: -l.1 7 Dl SYSTEM FAILS: You must indicate ei;r,er "Yes" or "No" as to each of the following: 1i. AID I have determined that the system violates one or more of the fqllowing 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. Yes No ent due to an overloaded or clogged SAS or cesspool. Backup of sewage into facility or system compon +`j.. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or 1 J. cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. #w Liquid depth in cesspool is.less than 6" below invert or available volume is less than 1/2 day flow. ; .�1. _ — Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). ;if 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. +. 3a rc 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. a 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. f• F El LARGE SYSTEM FAILS: ji You must indicate either "Yes" or "No" as to each of the following: The following criteria apply to large systems in addition to the criteria above: l /VD 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 — w 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) 'r _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 04/25/97) Page 3 of 10 I i;. 11` SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ' . PART B 19 CHECKLIST lr Property Address: �0Pt�< Owner: C'rfrj$L w. P Vt✓3 v rF Q Date of Inspection:. ;C Check if the following have been done: You must indicate either "Yes"\or "No" as to each of the following: Yes No 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 normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this-inspection. As built plans have been obtained and examined. Note if they are not available with N/A. — The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow. ; _ The site was inspected for signs of breakout. All system components, excluding the Soil Absorption System, have been located on 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. j The size and location of the Soil Absorption System on the site has been determined based on: — The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance o Sub-Surface Disposal System. — Existing information. Ex. Plan at B.O.H. v Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) 115.302(3)(b)J j i� I •: • tl 1, ii I is (revised 04/25/97) Page 4 of 10 4, i1 . ai SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: /�,q ROC tt y °,���/; P..n , /��f r✓Qo I/t lC l Owner: CrtA4417(�,' W, Ct?i.)E,Z . e9l Date of Inspection: _•a -77 i FLOW CONDITIONS t RESIDENTIAL: Design flow: Gd uD g.P.d./bedroom for S.A.S. Number of bedrooms: 4� i Number of current residents Garbage grinder(yes or no): 114 Laundry connected to system (yes or no):-±% Seasonal use (yes'or no): N© is Water meter readings, if available (last two (2) year usage (gpd): 17,0 Sump Pump (yes or no): /, Last date of occu ann'� G,i P { COMMERCIAUI NDUSTRIAL: 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 S system: (yes or no)_ Water meter readings, if available: Last date of occupancy: OTHER: (Describe) Last date of occupant},: t. GENERAL INFORMATION PUMPING RECORDS and source of information: . P UM A U AP-TV r',VS AFC T i61Q — o u p lyR System pumped as part of inspection: (yes or no)//b 1 If yes, volume pumped: gallons Reason for pumping: t fTYPE'OF SYSTEM''. Septictank/distribution box/soil absorption system Single cesspool .. Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) y I/A Technology etc. Copy of up to date contract? k Other is is APPROXIMATE AGE of all components, date installgd (if known) and source of information: `v� `QRS- �vJ !%r 1 ,� i Sewage odors detected when arriving at the site: (yes or no)1v �q , I (revised 04/25/97) Page 5 of 10 y �tf q: SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) T Property Address: Id-9 RoCK y /�Roo%' /C a• /V /'P''�6V:�� I' Owner: C11A1?1_M W Date of Inspection: BUILDING SEWER: (Locate on site plan) ; 4 Depth below grade: d" Material of construction: _cast iron _40 PVC_other (explain) a; Distance fro7Vrivate water supply well or suction line I Diameter `f 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) 25'i 7; If tank is metal, list age` Is age confirmed by Certificate of Compliance _(Yes/No) "0a „ Dimensions: /�L. S VJ X S A . cyCR o Sludge depth:__ Distance from top of sludge to bottom of outlet tee or baffler Scum thickness: O (No,$cM) i Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: 13 How dimensions were determined: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural k integrity,.evidence of leakage, etc.) GREASE TRAP::14 i, (locate on site plan) 1, Depth below grade: Material of construction: _concrete _meta! _Fiberglass _Polyethylene _other(explain) I' i' Dimensions: ` ! Scum thickness: j 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: �'.. li (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 K, �s .. (revised 04/25/97) Page 6 of 10 ,' l r,; TJ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: OL /Ur /Ian r.)v,,,e I Owner: G'>!/}RLr." ►!J- M-1 S' IC. Date of Inspection: 9- "1- F 7 TIGHT OR HOLDING TANK:i1//f (Tank must be pumped prior to, or at time, of inspection) I (locate on site plan) lj Depth below grade: h Material of'construction: _concrete _metal _Fiberglass _Polyethylene _other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm level: Alarm in working order _Yes; _ No Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) .,j DISTRIBUTION BOX:_ (locate on site plan) Depth of liquid level above outlet invert: I,i Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) (7-oodN0+'T!'6ry—. 4V4.L 0iS7/C o'j�V—,)',6N ; 9! i1 PUMP CHAMBER: A - 11 ). (locate on site plan) ,l I, Pumps in working order: (Yes or No) Alarms in working order (Yes or No) j Comments: ;g I` (note condition of pump chamber, condition of pumps and appurtenances, etc.) t. . ) (revised 04/25/97) Page 7 of 10 f. 1 71 J SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM �) _. PART C SYSTEM INFORMATION (continued) Property Address: Owner: 1 Tj' VV• C rt/L^e' .T"/Z, ; Date of Inspection: 7_ 7 7 SOIL ABSORPTION SYSTEM (SAS): f/ r (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: 't Type: leaching pits, number:_ I leaching chambers, number:_ ; i§ leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: r overflow cesspool, number: I Alternative system: ! Name of Technology: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) 1, CESSPOOLS: (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: . Indication of,groundwater. i 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.) ' .r fiA{ PRIVY: t j I (locate on site plan) _ (t !ti Materials of construction: Dimensions: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) :a ff..; e4'. (revised 04/25/97) page 8 of 10 ', .I i f, z k s i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Id q 8 o clC y atR soK R,Q, N, Pr"o e V 2'a Owner: C H4cP cots W e Nn$r>L R . { Date of Inspection: a 7_9 7 SKETCH OF SEWAGE DISPOSAL SYSTEM: 1 ; include ties to at least two permanent references landmarks or benchmarks j locate all wells within 100' (Locate where public water supply comes into house) if IN�`• r ,t a / t6 01 AI i I l (revised 09/25/97) e4 of 10 �D'7 x,y P R 00 (� l SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) IN Property Address: a I Owner: G Hf A,116 V✓,C H115d' V`R'. Date of Inspection: x7``17 ,;• is Depth to Groundwater Feet Please indicate all the methods used to determine High Groundwater Elevation: III I ✓Obtained from Design Plans on record " • i �� V Observation of Site (Abutting property, observation hole, basement sump etc.) {'i Determine it from local conditions { Check with local Board of health Check FEMA Maps #'.. Check pumping records , Y r Check local excavators, installers i i . Use USGS Data Describe in your own words how you established the High Groundwater Elevation. (Must be completed) ' hi N6) SL) IIv) o• VVA 7'2� ra. 6 D ter 6 i 14f r R, I II. ;j tit, (revised 04/25/97) Peg* 10 of 10 N: . t t;: 7T/Z 99 Vim-a, 17 a Q Oil, i 5i i ROCAY . j i y��a i ... j S I